Every finding on record at Vitas Healthcare Corporation of California

Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial & Comprehensive Assessment (an assessment to identify the physical, psychosocial [how a person thinks, feels, and interacts with others], emotional, and spiritual needs related to the terminal illness [a serious, incurable disease that doctors expect will lead to death, often within months] that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) of  the Patient was met as follows: --- 1. The HA failed to ensure the correct route of administration when multiple medication orders were written as oral for Patient 6, who had a diagnosis of dysphagia (difficulty swallowing), an active nothing by mouth (NPO, the patient cannot have anything to eat or drink) order, and a gastrostomy tube (tube inserted through the wall of the abdomen directly into the stomach) in place.  This failure had the potential to cause asphyxiation and over medication leading to hospitalization and or death. (Refer to L524). 2. The HA failed to ensure that the drug profile list (a comprehensive record of a patient's entire medication regimen used by healthcare professionals to manage care and prevent errors) was reviewed for six of 19 sampled patients (Patient 3, Patient 4, Patient 6, Patient 10, Patient 11 and Patient 15) to ensure the following:  2a. Two of 19 sampled patients (Patient 3 and Patient 4’s) medications were in accordance with the physician’s order as written in the drug profile list.    - Patient 3 did not have melatonin (prescription medication used to help manage certain sleep problems) 5 milligram (mg, unit of measurement) tablet and morphine sulfate (a type of pain medication used to treat moderate to severe pain) 20 milligram per milliliter (mg/mL, unit of measurement) solution available on hand for administration, as ordered by the physician and as written in the patient’s drug profile list.  - Patient 3 had simethicone (anti-gas medication used to relieve uncomfortable symptoms of excess gas) 80 mg chewable tablet available on hand instead of simethicone 125 mg chewable tablet as ordered by the physician and as written on the drug profile list.  - Patient 3 had losartan potassium (a prescription medication primarily used to treat high blood pressure) 100 mg tablet available on hand instead of losartan potassium 25 mg tablet as ordered by the physician and as written on the drug profile list.   - Patient 4’ had moxifloxacin hydrochloride (antibiotic used to treat bacterial eye infections) 0.5% ophthalmic solution (eye drops) and furosemide (medication used to help the body get rid of excess salt and water by increasing urine production) 20 mg tablet, take 1 tablet by mouth every day for heart failure, were written in Patient’s 4 drug profile that Patient 4 was currently taking but Patient 4’s caregiver (CG) 2 stated moxifloxacin hydrochloride was discontinued on 9/18/2025 and furosemide was discontinued on 8/27/2025.  2b. Four of 19 sampled patients (Patient 3, Patient 10, Patient 11, and Patient 15) controlled drugs (medications that the use and possession of are controlled by the federal government) were reviewed and counted, to ensure accuracy of administration, with each nurse visit.     2c. Two of 19 sampled patients (Patient 3 and Patient 6’s) drug profile list was reviewed to identify duplicate medication orders:  - Patient 3 had an order for morphine sulfate 20 mg/ml solution to take 0.25 ml (5 mg) by mouth every four hours as needed for pain with a start date of 10/13/2025 and morphine sulfate 20 mg/ml solution take 0.25 ml (5 mg) by mouth every four hours as needed for pain with a start date of 12/12/2025.  -Patient 6 had an order for Hydrocodone bitartrate and acetaminophen (medication for pain management) 5mg-325mg tablet by mouth ordered on 8/29/2025 and hydrocodone bitartrate and acetaminophen 5mg-325mg tablet (via gastronomy tube [g-tube, a soft tube placed through the abdominal wall directly in the stomach used to deliver nutrition, fluids, and medication]), ordered 8/29/2025. Atorvastatin (medications to lower cholesterol and triglycerides [fats] levels to help prevent heart disease, chest pain, strokes and heart attacks) 40 mg tablet (by mouth), ordered 8/29/2025 and atorvastatin 40 mg tablet (via g-tube), ordered on 8/29/2025.  These failures had the potential to result in medication administration errors and lack of controlled substance accountability, potentially resulting in unsafe medication administration, delayed or inappropriate symptom management, and drug diversion (the illegal redirection of prescription medications from their intended use or patient for abuse, addiction, or financial gain). (Refer to L530).  The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of Patient to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits.

Based on interview and record review the Hospice Agency (HA – agency providing care to terminally ill patients who have six months or less to live) failed to ensure the correct route of administration when multiple medication orders were written as oral for Patient 6, who had a diagnosis of dysphagia (difficulty swallowing), an active nothing by mouth (NPO, the patient cannot have anything to eat or drink) order, and a gastrostomy tube (tube inserted through the wall of the abdomen directly into the stomach) in place.  This failure had the potential to cause asphyxiation and over medication leading to hospitalization and or death. --- During a review of Patient 6’s “Case Sheet,” dated 12/18/2025, indicated the HA admitted Patient 4 on 7/2/2025 for the diagnoses including but not limited to Alzheimer's (a disease characterized by a progressive decline in mental abilities) dementia (a progressive state of decline in mental abilities) and dysphagia (difficult swallowing). During a record review titled “Initial Comprehensive Assessment Encounter” for Patient 6, dated 8/29/2025, authored by Registered Nurse 4 (RN), the “Initial Comprehensive Assessment Encounter” indicated, -Gastrostomy tube [g-tube, a soft tube placed through the abdominal wall directly in the stomach used to deliver nutrition, fluids, and medication]) feeding, “NPO” (Nothing by mouth). -Morphine Sulfate (medication for pain) 20mg/ml (milligrams per milliliters) solution take 0.25ml (five (5) mg) by mouth every four (4) hours as needed for pain.-Ondansetron HCL (medication for nausea) four (4) mg (milligrams) tablet (take 1 tablet (=4 mg) by mouth every 6 hours as needed for nausea and vomiting -Famotidine 40mg/5ml oral suspension (take five (5) ml (40mg) by mouth every night at bedtime for gastroesophageal reflux disease)-Baclofen 10mg tablet (take ½ (one-half) tablet (=5mg) by mouth 3 times a day for muscle spasm)-Clopidogrel bisulfate 75mg tablet (take 1 tablet (=75mg) by mouth every day for platelet aggregation inhibition)-Atorvastatin calcium 40 mg tablet (take 1 tablet (= 40 mg) by mouth every night at bedtime for hypercholesterolemia) During a record review titled “Plan of Care” (POC), dated 12/15/2025, the POC indicated the following orders:-Gastrointestinal dysphasia start date 8/29/25 2:45 AM -Diet consistency NPO start 9/15 25 and 9:55 AM-Hydrocodone bit/acetaminophen 5mg- 325mg tablet, take one tablet by mouth every four hours as needed for pain -Vitamin B-1 thiamine HCL 100 mg tablet, take one tablet 100 mg by mouth every day for nutritional deficiency-Anastrozole take one tablet 1mg tablet, take 1 tablet by mouth every day for carcinoma of breast-Baclofen 10mg tablet, take ½ a tablet (5mg) by mouth three times a day for muscle spasm-Atorvastatin calcium 40mg tablet, take 1 tablet (40mg) by mouth at bedtime for hypercholesterolemia-Famotidine 40mg/5ml oral suspension, take 5 ml (40mg) by mouth every night at bedtime for gastroesophageal reflux disease-morphine sulfate 20mg/ml solution, take 0.25ml (5mg) by mouth every 4 hours as needed for pain-Ondansetron HCL 4 mg tablet, take one tablet (4mg) by mouth every 6 hours as needed for nausea and vomitingDuring a concurrent interview and record review on 12/18/2025 at 9:34 a.m., with Register Nurse Case Manager 2 (RNCM), Patient 6’s “Initial Comprehensive Assessment Encounter” dated 8/29/2025 and POC dated 12/15/2025 were reviewed. Patient 6 “Initial Comprehensive Assessment Encounter” indicated pt was NPO and had taken by mouth medication orders. Patient 6’s POC indicated pt was NPO and had taken by mouth medication orders. RNCM 2 stated Patient 6 had an order for NPO and medication orders to be taken orally. RNCM 2 stated the orders were a total discrepancy that were overlooked by him putting Patient 6 in danger. RNCM 2 stated “ultimately” it was his responsibility to oversee and verify the orders placed. During an interview on 12/18/2025 at 10:45 a.m. with Physician 1, Physician 1 stated Patient 6 has a diagnosis of dysphagia and protrusion of the tongue which would make it unsafe for Patient 6 to take any medication or food by mouth. Physician 1 stated pt can asphyxiate if given medication or food orally. Physician 1 stated she “overlooked” the orders that needed to be reviewed, approved, and signed by her.  During a review of HA Policy & Procedure (P&P) titled “Initial and Comprehensive Assessment”, dated 12/8/2025, P&P indicated the following:·       Initial Comprehensive assessment RN overview consists of:  RN initial comprehensive assessment encounter and POC  ·       Updated comprehensive assessment demonstrates that all members of the interdisciplinary team (IDG) are actively involved in evaluating the patient's care including: identification of the care and needs of the patient based on assessment; ongoing assessment and monitoring of symptoms; provision of care plan interventions; recent accurate information about the patient/family to identify when changes to the POC are needed.  During a review of the Hospice Agency’s policy and procedure (P&P) titled, “Pharmacy Process,” (undated), the P&P indicated the following:  “Nursing Visit Pharmacological Overview: ensure medication bottles with labels or medication list is at the location of care... Each Nursing Updated Comprehensive Assessment Visits begins with a review of the patient’s Plan of Care (POC) which included current medications... Complete and document patient assessment including... availability of medications. Monitor medication amounts every visit, and order refills to ensure adequate supply in place until next visit... Assess for medication adverse event (an undesired effect of a drug or other type of treatment,) ... Ensure that the pharmacological orders are transcribed onto all appropriate places... update the POC.”   “The Chart Medication List should be reviewed during each patient visit and during Interdisciplinary Group to ensure it is up to date including active and discontinued medications.”    “Pharmacy Oversight Completed by Physician: prescribed, over the counter, herbal, and alternate medications that could affect drug therapy are reviewed by the physician to include effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring... If any medication issues are identified the physician should utilize the pharmacy or pharmacist as a resource.”

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the drug profile list (a comprehensive record of a patient's entire medication regimen used by healthcare professionals to manage care and prevent errors) was reviewed for six of 19 sampled patients  (Patient 3, Patient 4, Patient 6, Patient 10, Patient 11 and Patient 15) to ensure the following:   1. Two of 19 sampled patients (Patient 3 and Patient 4’s) medications were in accordance with the physician’s order as written in the drug profile list.    - Patient 3 did not have melatonin (prescription medication used to help manage certain sleep problems) 5 milligram (mg, unit of measurement) tablet and morphine sulfate (a type of pain medication used to treat moderate to severe pain) 20 milligram per milliliter (mg/mL, unit of measurement) solution available on hand for administration, as ordered by the physician and as written in the patient’s drug profile list.    - Patient 3 had simethicone (anti-gas medication used to relieve uncomfortable symptoms of excess gas) 80 mg chewable tablet available on hand instead of simethicone 125 mg chewable tablet as ordered by the physician and as written on the drug profile list.    - Patient 3 had losartan potassium (a prescription medication primarily used to treat high blood pressure) 100 mg tablet available on hand instead of losartan potassium 25 mg tablet as ordered by the physician and as written on the drug profile list.     - Patient 4 had moxifloxacin hydrochloride (antibiotic used to treat bacterial eye infections) 0.5% ophthalmic solution (eye drops) and furosemide (medication used to help the body get rid of excess salt and water by increasing urine production) 20 mg tablet, take 1 tablet by mouth every day for heart failure, were written in Patient’s 4 drug profile that Patient 4 was currently taking but Patient 4’s caregiver (CG) 2 stated moxifloxacin hydrochloride was discontinued on 9/18/2025 and furosemide was discontinued on 8/27/2025.    2. Four of 19 sampled patients (Patient 3, Patient 10, Patient 11, and Patient 15’s) controlled drugs (drugs with a potential for abuse or dependence, and their manufacture, possession, and use are heavily regulated by the government) were reviewed and counted, to ensure accuracy of administration, with each nurse visit.       3. Two of 19 sampled patients (Patient 3 and Patient 6’s) drug profile list were reviewed to identify duplicate medication orders:     - Patient 3 had an order for morphine sulfate 20 mg/ml solution 0.25 ml by mouth every four hours as needed for pain ordered on 10/13/2025 and morphine sulfate 20 mg/ml solution 0.25 ml by mouth every four hours as needed for pain ordered on 12/12/2025.    - Patient 6 had an order for Hydrocodone bitartrate and acetaminophen (medication for pain management) 5mg-325 mg tablet by mouth ordered on 8/29/2025 and hydrocodone bitartrate and acetaminophen 5mg-325mg tablet (via gastronomy tube [g-tube, a soft tube placed through the abdominal wall directly in the stomach used to deliver nutrition, fluids, and medication]), ordered 8/29/2025. Atorvastatin (medications to lower cholesterol and triglycerides [fats] levels to help prevent heart disease, chest pain, strokes and heart attacks) 40 mg tablet (by mouth), ordered 8/29/2025 and atorvastatin 40 mg tablet (via g-tube), ordered on 8/29/2025.    These failures had the potential to result in medication administration errors and lack of controlled substance accountability, potentially resulting in unsafe medication administration, delayed or inappropriate symptom management, and drug diversion (the illegal redirection of prescription medications from their intended use or patient for abuse, addiction, or financial gain).    On 12/18/2025, at 2:37 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the Hospice Agency’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Vice President of Operations (VPO) and National Patient Care Administrator (NPCA) 2, for failure to ensure that the drug profile was reviewed to ensure accuracy for six of 19 sampled patients (Patient 3, Patient 4, Patient 6, Patient 10, Patient 11 and Patient 15). These failures had the potential to result in medication administration errors and lack of controlled substance accountability, potentially resulting in unsafe medication administration, delayed or inappropriate symptom management, and drug diversion (the illegal redirection of prescription medications from their intended use or patient for abuse, addiction, or financial gain).   On 12/19/2025 at 4:52 p.m. the HA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely).    On 12/19/2025, at 5:04 p.m., the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the VPO, NPCA 2, Administrator and virtual attendees NPCA 1, Senior Vice President of Operations (SVPO) 1 and SVPO 2, with the IJ situations not removed.   On 12/29/2025 at 1:58 PM, the agency submitted an acceptable IJ removal plan (include all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely) was reviewed and accepted. On 12/29/2025, the survey team conducted an onsite visit to the agency and verified the IJ implementation. The IJ was removed on 12/29/2025 at 3:45 p.m., in the presence of the Administrator. --- Findings:   1a. During a review of Patient 3’s “Case Sheet,” (page of the medical chart containing a summary of basic patient information) dated 12/11/2025, the “Case Sheet” indicated the HA admitted Patient 3 on 10/13/2025, with diagnoses that included malignant neoplasm of head of pancreas (aggressive tumor in the pancreas [organ that aides in digestion and blood sugar control] that grows uncontrollably, interfering with normal functions) and hypertension (HTN, high blood pressure) and HTN.    During a review of Patient 3’s “Plan of Care (POC),” dated 12/9/2025, the “POC” indicated the following medication orders:   - Simethicone 125 mg chewable tablet. Chew one tablet by mouth every 6 hours as needed for gas for abdominal distention. Start date 11/2/2025.   - Losartan potassium 25 mg tablet. Take one tablet by mouth every day for high blood pressure and hold for systolic blood pressure (the top number in a blood pressure reading, showing the force in the arteries when the heart beats and pushes blood out) less than 110 for HTN. Start date 10/13/2025.     - Melatonin 5 mg tablet. Take 1 tablet by mouth at bedtime for sleep for insomnia. Start date 10/14/2025.   - Morphine sulfate 20 mg/mL solution. Take 0.25 mL by mouth every 4 hours as needed for pain. Start date 10/13/2025.    During a concurrent observation and interview on 12/12/2025 at 11:40 a.m., Licensed Vocational Nurse (LVN) 1 was observed in Patient 3’s home conducting medication reconciliation (a formal process of creating the most accurate list of a patient's current medications and comparing it to the medications the patient is taking or should be taking to identify and resolve discrepancies). Patient 3 brought out all the medications he was taking and LVN 1 reviewed and compared Patient 3’s medication bottles to the patient’s drug profile list. Patient 3’s melatonin 5 mg tablet and morphine sulfate 20 mg/mL solution were missing from Patient 3’s medications available on hand. Patient 3 stated he brought out all the medications he was taking, and he did not have melatonin and was not using melatonin. Patient 3’s caregiver (CG) 1 stated he told the HA to stop ordering the Morphine because Patient 3 did not use it and the HA continued providing the medication. Patient 3’s CG 1 stated he had thrown Patient 3’s Morphine down the drain.    During a concurrent observation at Patient 3’s home and record review on 12/12/2025 at 11:40 a.m., Patient 3’s “Plan of Care,” dated 12/9/2025 was reviewed. The “Plan of Care” indicated Patient 3 have an order for simethicone 125 mg chewable tablet and losartan potassium 25 mg tablet but observed Patient 3 medication on hand were simethicone 80 mg chewable tablet and losartan potassium 100 mg tablet.   During an interview on 12/15/2025 at 2:16 p.m. with LVN 1, LVN 1 stated medication reconciliation was done by reviewing a patient’s medication list and comparing the list with the patient’s medications on hand. LVN 1 stated that any discrepancies from the medication reconciliation were reported to the Registered Nurse Case Manager (RNCM) or the physician. LVN 1 stated this process ensures the medications a patient was taking match the medications the hospice agency has on file.  LVN 1 stated an accurate medication log ensures proper medication supply and keeps the patient informed on safe medication administration.   During a continued interview on 12/15/2025 at 2:16 p.m. with LVN 1, LVN 1 stated that when a patient refuses medication and decides to dispose of it, it would be documented in the patient’s medical record.    During an interview on 12/16/2025 at 1:27 p.m. with NPCA 1, NPCA 1 stated that the medication reconciliation process includes comparing a patient’s medication bottles with the patient's medication list to ensure the patient has all the medications listed. NPCA 1 stated that the medication reconciliation process is a review of all medications such as prescribed medication and controlled substances (a drug hose production, possession, and use are strictly monitored by the government due to high potential for abuse or addiction, classified into schedules based on risk to regulate access and prevent misuse). NPCA 1 stated that all the medications on the list must be visualized by the visiting nurse (Licensed Vocational Nurse (LVN) or Registered Nurse (RN). NPCA 1 stated the visiting nurse reviews the medication name, medication dose and the frequency of administration with the patient and then asks the patient if they were still taking the medication. NPCA 1 stated that if a medication was missing, lost, or misplaced the nurse should first clarify with the patient that they were still taking the medication and then contact the physician to verify whether the medication was required. NPCA 1 stated that if a patient’s medication list was not accurate a patient might be taking medications that were no longer necessary.   During an interview on 12/16/2025 at 1:36 p.m. with NPCA 1, NPCA 1 stated that if a patient or patient family member verbalized that they do not want to receive morphine, the medication would not be prescribed or an order to discontinue the medication would be obtained from the physician. NPCA 1 stated that if an order for morphine was discontinued, the hospice nurse would provide education about safe disposal of controlled medications to the patient and/or patient family members.   During a review of the Hospice Agency’s policy and procedure (P&P) titled, “Pharmacy Process,” (undated), the P&P indicated the following:   “Nursing Visit Pharmacological Overview: ensure medication bottles with labels or medication list is at the location of care... Each Nursing Updated Comprehensive Assessment Visits begins with a review of the patient’s Plan of Care (POC) which included current medications... Complete and document patient assessment including... availability of medications. Monitor medication amounts every visit, and order refills to ensure adequate supply in place until next visit... Assess for medication adverse event (an undesired effect of a drug or other type of treatment,) ... Ensure that the pharmacological orders are transcribed onto all appropriate places... update the POC.”    “The Chart Medication List should be reviewed during each patient visit and during Interdisciplinary Group to ensure it is up to date including active and discontinued medications.”     “Pharmacy Oversight Completed by Physician: prescribed, over the counter, herbal, and alternate medications that could affect drug therapy are reviewed by the physician to include effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring... If any medication issues are identified the physician should utilize the pharmacy or pharmacist as a resource.”    1b. During a review of Patient 4’s “Case Sheet,” dated 12/11/2025, indicated the HA admitted Patient 4 on 7/2/2025 for the diagnoses including but not limited to cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), and vascular dementia (impaired supply of blood to the brain, such as may be caused by a series of small strokes).   During a concurrent observation, interview and record review, on 12/12/2025 at 12:15 p.m., with Registered Nurse (RN) 3 in Patient 4’s home, Patient 4’s medication reconciliation was conducted with RN 3 during Patient 4’s home visit. Patient 4’s “Medication List,” dated 12/11/2 025, indicated the following medications: Moxifloxacin Hcl 0.5%, instill 1 drop into left eye four (4) times daily for bacterial eye infection, start date of 7/2/2025. Furosemide 20mg tablet, take 1 tablet by mouth every day for heart failure, start date of 7/2/2025. Patient 4’s CG 2 brought out the medications and stated the patient’s ophthalmologist discontinued the moxifloxacin on 9/18/2025 and the patient’s cardiologist discontinued the furosemide on 8/27/2025.   During a concurrent interview and record review on 12/16/2025 at 12:39 p.m. with NPCA 1, NPCA 1 stated Patient 4’s “Medication List” dated 12/11/2025, indicated the moxifloxacin (antibiotic for bacterial infection) and furosemide (medication to increase urine output) were listed as Patient 4’s active medications. NPCA 1 stated medication reconciliation should be done by license personnel with patients and family at every home visit. NPCA 1 stated after reviewing the patient’s medications, the hospice physician should be notified for any discrepancies. NPCA 1 stated that taking medications that have been discontinued can be harmful to the patient.   During a review of the Hospice Agency’s P&P titled, “Pharmacy Process,” undated, the P&P indicated, “Each Nursing Updated Comprehensive Assessment Visits begins with a review of the patient’s Plan of  Care (POC) which included current medications…Pharmacy oversight completed by Physician…The CML (Chart Medication List) should be reviewed during each patient visit and during IDG (interdisciplinary group) to ensure it is up to date including active and discontinued medications…”   2a. During a review of Patient 3’s “Case Sheet,” dated 12/11/2025, the “Case Sheet” indicated the HA admitted Patient 3 on 10/13/2025, with diagnoses that included malignant neoplasm of head of pancreas and HTN.   During a review of Patient 3’s “Plan of Care (POC),” dated 12/9/2025, the “POC” indicated the following medication order: morphine sulfate 20 mg/mL solution. Take 0.25 mL by mouth every four (4) hours as needed for pain. Start date 10/13/2025.   During a review of Patient 3’s “RN Focus Encounter,” dated 11/2/2025, the “RN Focus Encounter” indicated, “Reviewed/ counted controlled substance(s) to ensure accuracy of administration since last visit: N/A (not applicable).”   During a review of Patient 3’s “LPN Focus Encounter,” dated 11/27/2025, 12/2/2025, 12/5/2025, and 12/9/2025, the “LPN Focus Encounter” indicated, “Reviewed/ counted controlled substance(s) to ensure accuracy of administration since last visit: N/A” or “Reviewed/ counted controlled substance(s) to ensure accuracy of administration since last visit: No.”   During a current interview and record review on 12/15/2025 at 2:16 p.m., with LVN 1, Patient 3’s “LPN Focus Encounter,” dated 12/12/2025 was reviewed. The “LPN Focus Encounter” indicated, “Reviewed/ counted controlled substance(s) to ensure accuracy of administration since last visit: N/A.” LVN 1 stated that a medication reconciliation, including a review and count of narcotics (a type of drug causing sleep/pain relief), should be done at every visit and documenting “N/A” was not appropriate and did not reflect that the required medication reconciliation was completed.    During a continued interview on 12/15/2025 at 2:16 p.m., with LVN 1, LVN 1 stated the medication reconciliation was important to ensure Patient 3 did not run out of medication and potentially experience unmanaged pain. LVN 1 stated that Patient 3 was at risk of experiencing overmedication (taking too many medications, or taking medication in doses that are too high, too often, or when they are not needed) with morphine sulfate potentially resulting in increased sedation (a state of calmness, relaxation, or sleepiness induced by medication) , confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness and more), or respiratory distress (difficulty breathing, evidenced by signs and symptoms such as shortness of breath, gasping for breath, hyperventilation [breathing that is faster and shallower than normal], or breathing that is uncomfortable or painful).    During an interview on 12/16/2025 at 1:27 p.m., with NPCA 1, NCPA 1 stated that the medication reconciliation, including a review and count of controlled substances, should be completed by all nurses (LVN and RN) at each patient visit. NCPA 1 stated that documenting “N/A” on the nursing encounters under the section “Reviewed/ counted controlled substance(s) to ensure accuracy of administration since last visit” meant not applicable or that controlled substances were not reviewed and counted. NPCA 1 stated that documenting “No” on the nursing encounters under the same section meant the controlled substance review and count was not done.    During an interview on 12/16/2025 at 1:56 p.m., with NPCA 1, NCPA 1 stated that patients were at risk of experiencing medication administration errors and poor symptom management when the nurses do not review and count controlled substances. NPCA 1 stated that patients were at risk of experiencing drowsiness (feeling sleepy, tired, or an abnormal urge to sleep), lethargy (feeling sluggish, drowsy, and lacking energy or enthusiasm), sleeping for longer periods, nausea and vomiting, slowed breathing, and decreased heart rate (bradycardia, typically under 60 beats per minute for adults). NPCA 1 stated that there was a risk of medication diversion.    During a review of the Hospice Agency’s P&P titled, “Pharmacy Process,” (undated), the P&P indicated the following:   “Nursing Visit Pharmacological Overview: ensure medication bottles with labels or medication list is at the location of care... Each Nursing Updated Comprehensive Assessment Visits begins with a review of the patient’s Plan of Care (POC) which included current medications... Complete and document patient assessment including... availability of medications. Monitor medication amounts every visit, and order refills to ensure adequate supply in place until next visit... Assess for medication adverse event... Ensure that the pharmacological orders are transcribed onto all appropriate places... update the POC.”    “The Chart Medication List should be reviewed during each patient visit and during Interdisciplinary Group to ensure it is up to date including active and discontinued medications.”     2b. During a review of Patient 10’s “Case Sheet,” dated 12/17/2025, the “Case Sheet” indicated that the hospice agency admitted Patient 10 on 11/10/2025 with diagnoses that included hepatic failure (a life-threatening condition that occurs when the liver is severely damaged and loses its ability to perform its essential functions)  and anemia (a condition where the blood does not have enough healthy red blood cells or sufficient hemoglobin to carry adequate oxygen to the body's tissues).    During a review of Patient 10’s “Active Medications,” dated 12/17/2025, the “Active Medications” indicated the following medication orders:   - hydrocodone bitartrate and acetaminophen 10-325 tablet. Take 1 tablet by mouth every 6 hours as needed for pain. Start date 12/11/2025.   - morphine sulfate 20 mg/mL solution. Take 0.25 mL under the tongue every 4 hours as needed for pain and shortness of breath. Start date 11/11/2025.     During a concurrent interview and record review on 12/16/2025 at 1:53 p.m., with NPCA 1, Patient 10’s “LPN Focus Encounter,” dated 12/11/2025 and 12/13/2025 were reviewed. The “LPN Focus Encounter” indicated, “Reviewed/ counted controlled substance(s) to ensure accuracy of administration since last visit: N/A”. NPCA 1 stated that the visiting nurse did not review and count the controlled substances and that the remaining amount of hydrocodone bitartrate and acetaminophen and morphine sulfate should have been documented in the Focus Encounters.    During an interview on 12/16/2025 at 1:56 p.m., with NPCA 1, NCPA 1 stated that patients are at risk of experiencing medication administration errors and poor symptom management when the nurses do not review and count controlled substances. NPCA 1 stated that patients were at risk of experiencing drowsiness, lethargy, sleeping for longer periods, nausea and vomiting, slowed breathing, and decreased heart rate. NPCA 1 stated that there was a risk of medication diversion.   During a review of the Hospice Agency’s P&P titled, “Pharmacy Process,” (undated), the P&P indicated the following:   “Nursing Visit Pharmacological Overview: ensure medication bottles with labels or medication list is at the location of care... Each Nursing Updated Comprehensive Assessment Visits begins with a review of the patient’s Plan of Care (POC) which included current medications... Complete and document patient assessment including... availability of medications. Monitor medication amounts every visit, and order refills to ensure adequate supply in place until next visit... Assess for medication adverse event... Ensure that the pharmacological orders are transcribed onto all appropriate places... update the POC.”     “The Chart Medication List should be reviewed during each patient visit and during Interdisciplinary Group to ensure it is up to date including active and discontinued medications.”     2c. During a review of Patient 11’s “Case Sheet,” dated 12/17/2025, indicated that the hospice agency admitted Patient 11 on 11/25/2025 with diagnoses that included malignant neoplasm of colon (cancer that develops in the large intestine) and partial intestinal obstruction (a narrowing or blockage in the intestine that allows some liquid, gas, or stool to pass through).   During a review of Patient 11’s “Active Medications,” the “Active Medications” indicated the following medication orders:    - lorazepam 0.5 mg tablet. Take 1 tablet under the tongue every 6 hours as needed for nausea or vomiting. Start date 11/25/2025.   - lorazepam 0.5 mg tablet. Take 1 tablet under the tongue every 6 hours as needed for anxiety. Start date 11/28/2025.   - morphine sulfate 20 mg/mL solution. Take 0.5 mL by mouth every 2 hours as needed for moderate pain and 1 mL for severe pain. Start date 11/26/2025.     - morphine sulfate 20 mg/mL solution. Take 0.25 mL by mouth every 2 hours as needed for mild pain and 10 mg for severe pain. Start date 11/28/2025.   - fentanyl 25 micrograms (mcg, unit of measurement)/ hour patch TD72. Apply 1 patch topically to upper torso every 72 hours for pain. Start date 11/25/2025.    During a review of Patient 11’s “LPN Focus Encounter,” dated 11/25/2025, the “LPN Focus Encounter” indicated, “Reviewed/ counted controlled substance(s) to ensure accuracy of administration since last visit: No.”   During an interview on 12/16/2025 at 1:27 p.m., with NPCA 1, NCPA 1 stated that the medication reconciliation, including a review and count of controlled substances, should be completed by all nurses (LVN and RN) at each patient visit. NCPA 1 stated that documenting “N/A” under the section “Reviewed/ counted controlled substance(s) to ensure accuracy of administration since last visit” meant not applicable or that controlled substances were not counted.    During an interview on 12/16/2025 at 1:56 p.m., with NPCA 1, NCPA 1 stated that patients are at risk of experiencing medication administration errors and poor symptom management when the nurses do not review and count controlled substances. NPCA 1 stated that patients were at risk of experiencing drowsiness, lethargy, sleeping for longer periods, nausea and vomiting, slowed breathing, and decreased heart rate. NPCA 1 stated that there was a risk of medication diversion.   2d. During a review of Patient 15’s “RN (Registered Nurse) - Initial Comprehensive Assessment Encounter,” dated 12/9/2025, the “RN - Initial Comprehensive Assessment Encounter” indicated, Patient 15 was admitted to hospice care on 12/9/2025 with primary diagnosis of malignant neoplasm (an abnormal, uncontrolled growth of cells within the prostate gland {specific gland in the male reproductive system where the cancer originates} and that has the potential to spread  to other parts of the body and was on continuous care (Continuous Care – a short-term medical support {mostly nursing} at least eight {8} hours a day for hospice patient experiencing a symptom crisis, like severe pain, or in breathing distress, that their regular caregiver can’t manage by their own, allowing them to stay home and keeping them from going to the hospital) at home for pain management, care teaching, medication management, and restlessness.     During a further review of the “RN – Initial Comprehensive Assessment Encounter,” the “RN – Initial Comprehensive Assessment Encounter” indicated, Patient 15 had an order for morphine sulfate (an opioid analgesic primarily used for the management of moderate to severe pain) 15 mg (mg – a unit of measurement) tablet take ½ (one-half) to 1 tablet (=7.5 to 15 mg) by mouth every four (4) hours as needed for pain and lorazepam (a prescription medication used primarily as a short-term treatment to calm the brain and nervous system) 0.5 mg tablet take 1 tablet (0.5 mg) by mouth every four (4) hours as needed for anxiety (is the body's natural defense system, essentially acting as a built-in alarm that alerts you to potential danger or stress).    During a concurrent interview and record review, on 12/16/2025 at 2:39 p.m., with the NPCA (National Patient Care Administrator) 1, the Patient’s 15’s “CC Interval (Shift) Charting,” were reviewed and indicated the following:     - On 2/9/2025 at 4 p.m., morphine sulfate 15 mg tablet and lorazepam 0.5 tablet were given at 7:00 p.m. The “controlled substance counts at shift start and shift end” was blank.     - On 12/10/2025 at 12 a.m., lorazepam 0.5 mg tablet was given at 12 a.m., morphine 15 mg tablet was given at 12:15 a.m., and morphine 15 mg tablet and lorazepam 0.5 mg tablet were given at 4:00 a.m., and at 7:45 a.m. The “controlled substance counts at shift start and shift end,” had no medication count and indicated, “family managed meds.”   - On 12/10/2025 at 4:00 p.m., morphine 15 tablet and lorazepam 0.5 mg tablet were both given at 6 p.m. and at 10 p.m. The “controlled substance counts at shift start and at shift end” was blank.   - On 12/11/2025 at 12 a.m., morphine 15 mg tab and lorazepam 0.5 mg were both given at 2:00 a.m. and at 7:11 a.m. The “controlled substance counts at shift start and at shift end,” had no medication count and indicated, “family managed meds.”   During an interview on 12/16/2025 at 2:39 p.m. NPCA 1 stated that patient-controlled substances must be counted at the start and at the end of the nurse’s shift and counting the controlled substance before and after the shift was important to make sure that the patient was receiving the medications as appropriately prescribed to treat the specific symptom. NPCA 1 stated knowing the correct medication counts ensured that patients were taking the medications as prescribed and ensured that the symptoms were relieved and each nurse on shift care must document the patient’s-controlled substance count correctly as indicated in the Hospice Agency’s policy and procedure (P&P). NPCA 1 stated Patient 15’s lorazepam and morphine narcotic count were not conducted on 12/9/2025, 12/10/2025, and 12/11/2025. NPCA 1 stated the assigned nurses in Patient 15’s continuing care were not adhering with the P&P and that was concerning.   During a review of the Hospice Agency’s  P&P titled, “Continuous Care," dated 12/4/2025, the P&P indicated, “Controlled Substances…Shift LPN/LVNs and RNs should complete a count of all controlled substances at the beginning and end of their shift to ensure accuracy of administration since last visit.”   3a. During a review of Patient 3’s “Case Sheet,” dated 12/11/2025, the “Case Sheet” indicated the HA admitted Patient 3 on 10/13/2025, with diagnoses that included malignant neoplasm of head of pancreas and HTN.   During a concurrent interview and record review, on 12/16/2025 at 1:36 p.m. with NPCA 1, Patient 3’s “Plan of Care,” dated 12/16/2025 was reviewed. The “Plan of Care” indicated the following duplicate medication order:     - morphine sulfate 20mg/ml solution take 0.25ml by mouth every four (4) hours as needed for pain. Start date 10/14/2025.   -Morphine sulfate 20mg/ml solution take 0.25ml by mouth every four (4) hours as needed for pain. Start date 12/12/2025. NPCA 1 stated Patient 3 had duplicate morphine orders.   During an interview on 12/18/2025 at 10:45 a.m., Physician 1 stated she receives patient orders from the RNCMs, then she reviews the orders and signs the orders for the patients. Physician 1 stated having duplicate orders could cause patients to overdose.     During a review of the Hospice Agency’s P&P titled, “Pharmacy Process,” (undated), the P&P indicated the following:   -“Nursing Visit Pharmacological Overview: Each Nursing Updated Comprehensive Assessment Visits begins with a review of the patient’s Plan of Care (POC) which included current medications... Complete and document patient assessment including... availability of medications. Ensure that the pharmacological orders are transcribed onto all appropriate places... update the POC.”    -“The Chart Medication List should be reviewed during each patient visit and during Interdisciplinary Group to ensure it is up to date including active and discontinued medications.”     -“Pharmacy Oversight Completed by Physician: prescribed, over the counter, herbal, and alternate medications that could affect drug therapy are reviewed by the physician to include effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring... If any medication issues are identified the physician should utilize the pharmacy or pharmacist as a resource.”   3b. During a review of Patient 6’s “Case Sheet,” dated 12/18/2025, indicated the hospice agency admitted Patient 4 on 7/2/2025 for the diagnoses including but not limited to Alzheimer's (a disease characterized by a progressive decline in mental abilities) dementia (a progressive state of decline in mental abilities) and dysphagia (difficult swallowing).   During a concurrent interview and record review, on 12/18/2025 at 9:34 a.m., with Registered Nurse Case Manager 2 (RNCM 2), Patient 6’s “Initial Comprehensive Assessment Encounter,” dated 8/29/2025, indicated the following duplicate medication orders:    - hydrocodone bitartrate and acetaminophen 5mg-325mg tablet (take 1 tablet by mouth 2 times daily for pain)   - hydrocodone bitartrate and acetaminophen 5mg-325mg tablet (take 1 tablet via g-tube every 4 hours as needed for pain)   - atorvastatin 40mg tablet (take 1 tablet by mouth at bedtime for hypercholesterolemia)    - atorvastatin 40mg tablet (take 1 tablet via g-tube at bedtime for reducing cholesterol)   RNCM 2 stated Patient 6 had duplicate medication orders written on the “Initial Comprehensive Assessment Encounter.” RNCM 2 stated that ultimately it is his responsibility, and he should have verified that Patient 6’s medication orders were correct and not duplicated.     During an interview on 12/18/2025 at 10:45 a.m., Physician 1 stated she receives patient orders from the RNCMs, then she reviews and signs the orders. Physician 1 stated that she overlooked the duplicate medication orders for Patient 6 when she reviewed and signed the orders. Physician 1 stated having duplicate orders could cause the patient to overdose.     During a review of the Hospice Agency’s P&P titled, “Pharmacy Process,” (undated), the P&P indicated, “Each Nursing Updated Comprehensive Assessment Visits begins with a review of the patient’s Plan of  Care (POC) which included current medications…Pharmacy oversight completed by Physician…Prescribed, over-the-counter, herbal, and alternate medications that could affect drug therapy are reviewed by physician to include…duplicate drug therapy…The nurse calling the physician has the responsibility to inform the physician of medications the patient taking when ordering new drugs as the physician can only provide a review of medications known to them…The CML (Chart Medication List) should be reviewed during each patient visit and during IDG to ensure it is up to date including active and discontinued medications…only orders that have been approved by the physician are copied over to the electronic medical record”

Based on interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for interdisciplinary group (a collaborative team of healthcare professionals responsible for providing holistic care [concerned with the whole person, animal, or organism as opposed to a specific part or aspect] to hospice patients and their families), care planning, coordination of services was not met as follows: --- 1. The HA failed to ensure one of 19 sampled patients (Patient 1’s) new wound on the coccyx (a small triangular bone at the base of the spinal column), identified on 9/20/2025, was not assessed by a Registered Nurse (RN).   2. The HA failed to ensure Patient 1’s new wound on the coccyx, identified on 9/20/2025, did not have a treatment plan.These failures had the potential to delay treatment that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death. (Refer to L540). 3. The HA failed to ensure to clarify orders for medications to be taken orally for one of 19 sampled patient (Patient 6) who had diagnosis of dysphagia (difficulty swallowing) and had an order to be NPO (nothing by mouth). This failure had the potential to cause asphyxiation (inadequate oxygen supply to the body) and over medication leading to hospitalization and or death. (Refer to L549)The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Interdisciplinary group, care planning, coordination of services are provided to patients certified to receive home health benefits.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to assess and develop a treatment care plan for one of 19 sampled patients (Patient 1) when, Patient 1’s new wound on the coccyx (a small triangular bone at the base of the spinal column,) identified on 9/20/2025, was not assessed by a Registered Nurse (RN) and Patient 1’s new wound on the coccyx, identified on 9/20/2025, did not have a treatment plan.    These failures had the potential to delay treatment that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death.     On 12/16/2025, at 4:26 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the Hospice Agency’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Vice President of Operations (VPO) and National Patient Care Administrator (NPCA) 2, for failure to assess and develop a treatment care plan for one of 19 sampled patients (Patient 1). These failures had the potential to delay treatment that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death.   On 12/19/2025 at 11:38 a.m. p.m. the HA was able to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) but have not implemented the IJRP.   On 12/19/2025, at 5:04 p.m., the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the VPO, NPCA 2, Administrator and virtual attendees NPCA 1, Senior Vice President of Operations (SVPO) 1 and SVPO 2, with the IJ situations not removed. --- Findings:   During a review of Patient 1’s “Admission Record,” indicated the HA admitted Patient 1 on 8/27/2025 with diagnoses including but not limited to nontraumatic subdural hemorrhage (bleeding of blood in the space between the brain and its outer covering), vascular dementia (impaired supply of blood to the brain, such as may be caused by a series of small strokes), and hypertension (HTN, high blood pressure).     During a review of Patient 1’s “Focus Encounter (nurses notes),” dated 9/20/2025, authored by Telecare Registered Nurse (TRN), indicated Patient 1’s Care Giver (CG 3) notified the HA regarding concerns of Patient 1’s open wound to the coccyx and having diarrhea.    During a review of Patient 1’s “Focus Encounter,” dated 9/20/2025, at 3:53 p.m., authored by Licensed Vocational Nurse (LVN) 1, indicated Patient 1 had a wound on coccyx, erythema (reddening of the skin) surrounding wound, 20% wound tissue, 80% wound tissue granulation (the new, pinkish-red, moist connective tissue with tiny blood vessels that forms on the surface of a healing wound, acting as a foundation to fill the defect and allow new skin to grow over it.) Measuring; 1.00 cm (centimeters) in length, 1.00 cm in width, 0.10 cm in depth.    During a review of Patient 1’s “Focus Encounter,” dated 9/23/2025 at 2:40 p.m., authored by RN 1, indicated Patient 1 had an order for “Apply low air loss mattress related to stage 2 sacral wound (Partial-thickness loss of skin, presenting as a shallow open sore or wound.” There was no documentation of wound measurement/wound assessment of Patient 1’s sacral (coccyx) wound.     During a review of Patient 1’s “Focus Encounter,” dated 9/23/2025 at 6:57 p.m., authored by Chaplain, indicated, “when dropping off wound supplies (at Patient 1’s house) CG 3 expressed frustration surrounding HA services and overall care.” There was no documentation of itemized wound supplies delivered to Patient 1.    During a review of Patient 1’s “Focus Encounter,” dated 9/25/2025 at 12:45 p.m., authored by RNCM, indicated CG 3 refusing care (five days after LVN 1’s visit on 9/20/2025 regarding CG 3 concerns on Patient 1’s open wound on the coccyx and diarrhea).    During a concurrent interview and record review on 12/16/25 at 10:10 a.m., Patient 1’s focus encounter, physician order and care plan from 8/28/2025 to 9/30/2025 were reviewed. The focus encounter indicated Patient 1 had new wound that developed on 9/20/2025. The RNCM stated patient having new pressure ulcer was considered a change of condition and that a Registered Nurse (RN) should make a home visit to assess the patient’s wound within 24 hours. The RNCM stated there was no follow up visit done by RN 1 after LVN 1’s initial visit on 9/20/2025. The RNCM stated when a patient with a pressure ulcer has diarrhea, there is an increased risk of further skin breakdown and infection.  The RNCM stated Patient 1’s record had no documentation of wound care order for the coccyx and there was no documentation that a treatment care plan for Patient 1’s pressure ulcer was developed. The RNCM stated there should be a plan of care developed addressing the patient’s skin integrity and pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence.)      During an interview on 12/16/25 at 12:39 p.m. with National Patient Care Administrator 1 (NPCA)/ Director of Patient Care Services (DPCS) designee, NPCA 1 stated that an LVN can assess the patient, if a RN was not available, when there is a change of condition, however, “must absolutely be followed up by a RN.” The NPCC stated the RN must document interventions provided to the patient on the “Focus Encounter”.    During a review of “(name of the Hospice agency Patient 1 transferred to) Hospice and Palliative Care Transfer Form,” dated 9/28/2025, indicated, “reason: neglect of patient, effective date: 9/28/2025.”    During a review of Patient 1’s “Plan of Care,” dated 9/30/2025, indicated Patient 1 had sacral wound staged 2.   A review of HA Registered Nurse Job description dated 8/23/2025 indicated, to document interactions with patients, families to include the assessment, plan of care, any actions and interventions and the resolution of each patient/family interactions at the time of the event…Provides education and training to patients, families, caregivers, and referral sources in the care of the patient, including pain management.”    A review of HA’s P&P titled, “Things Hospice Innovators Need to Know About: Wounds,” dated 10/2020, the P&P indicated, “A thorough assessment of the patient, the patients skin condition and risk status for pressure and skin breakdown development is essential for prevention and treatment…Hospice appropriate approach to care: prevention of infection…Care Planning, Interventions should be assessment based: RN to discuss wounds, goals of care, with patient/family; RN to instruct wound, dressing changes, with family; RN to ensure wound, return demonstration of dressing change, by family.”      A review of the HA’s P&P titled, “Symptom Management,” dated 11/5/2025, the P&P indicated, “RNs are responsible for in-depth assessments which include both data collection and analysis of assessment findings. LVN complete the first portion of assessment, which is data collection.”

Based on interview and record review the Hospice Agency (HA – agency providing care to terminally ill patients who have six months or less to live) failed to ensure to clarify orders for medications to be taken orally for one of 19 sampled patient (Patient 6) who had diagnosis of dysphagia (difficulty swallowing) and had an order to be NPO (nothing by mouth). This failure had the potential to cause asphyxiation (inadequate oxygen supply to the body) and over medication leading to hospitalization and or death. --- During a review of Patient 6’s “Admission Record,” dated 12/18/2025, indicated the HA admitted Patient 6 on 8/28/2025 for the diagnoses including but not limited to Alzheimer's (a disease characterized by a progressive decline in mental abilities) dementia (a progressive state of decline in mental abilities) and dysphagia (difficult swallowing).   During a record review titled “Initial Comprehensive Assessment Encounter” for Patient 6, dated 8/29/2025, authored by Registered Nurse (RN) 4, the “Initial Comprehensive Assessment Encounter” indicated the following orders:   -Patient 6 had an order for gastrostomy tube (g-tube, a soft tube placed through the abdominal wall directly in the stomach used to deliver nutrition, fluids, and medication) feeding, start date 8/29/2025.  -Patient 6 had an order for “NPO” (Nothing by mouth), start date 8/29/2025.  -Patient 6 had an order for morphine sulfate (medication for pain) 20 mg/ml (milligrams per milliliters) solution take 0.25ml (5mg) by mouth every four hours as needed for pain, start date 8/29/2025. -Patient 6 had an order for ondansetron hydrochloride (medication for nausea) four (4) mg (milligrams) tablet take 1 tablet (4 mg) by mouth every six hours as needed for nausea and vomiting, start date 8/29/2025.  -Patient 6 had an order for famotidine (medication used to reduce the amount of acid produced by the stomach) 40mg/5 ml oral suspension take 5 ml (40 mg) by mouth every night at bedtime for gastroesophageal reflux disease (a chronic condition where stomach acid frequently flows back into the throat), start date 8/29/2025.  -Patient 6 had an order for baclofen (medication used for skeletal muscle relaxant) 10mg tablet (take one-half tablet [5mg] by mouth three times a day for muscle spasm) start date 8/29/2025.  -Patient 6 had an order for clopidogrel bisulfate (medication used to prevent serious cardiovascular events like heart attacks and strokes) 75mg tablet one tablet by mouth every day for platelet aggregation inhibition prevent blood platelets from sticking together to form clots, start date 8/29/2025.  -Patient 6 had an order for atorvastatin calcium (medication to treat high cholesterol) 40 mg tablet (take 1 tablet [40 mg] by mouth every night at bedtime for hypercholesterolemia [excess cholesterol in the bloodstream]), start date 8/29/2025.  During a record review of Patient 6’s “Plan of Care” (POC), dated 12/15/2025, the POC indicated the following:  -Patient 6 had diagnosis of Dysphasia on 8/29/2025.  -Patient 6 had an order for NPO on 9/15/2025.  -Patient 6 had an order for Hydrocodone bitartrate/acetaminophen (medication used to manage moderate to severe pain) 5mg- 325mg tablet, take one tablet by mouth every four hours as needed for pain, start date 9/2/2025.  -Patient 6 had an order for Vitamin B-1 thiamine HCL (water soluble vitamins essential for converting food into energy, supporting nerve, and heart health and helping enzymes function correctly) 100mg tablet, take one tablet 100 mg by mouth every day for nutritional deficiency, start date 8/30/2025. -Patient 6 had an order for Anastrozole (medication used to treat early breast cancer) take one 1mg tablet, take one tablet by mouth every day for carcinoma (cancer) of breast, start date 8/28/2025.  -Patient 6 had Baclofen 10mg tablet, take one-half a tablet (5mg) by mouth three times a day for muscle spasm, start date 8/28/2025.  -Patient 6 had Atorvastatin calcium 40mg tablet, take one tablet (40mg) by mouth at bedtime for hypercholesterolemia, start date 8/28/2025.  -Patient 6 had Famotidine 40mg/5ml oral suspension, take 5ml (40mg) by mouth every night at bedtime for gastroesophageal reflux disease, start date 8/28/2025.  -Patient 6 had an order for Morphine sulfate 20mg/ml solution, take 0.25ml (5mg) by mouth every four hours as needed for pain, start date 8/28/2025.  -Patient 6 had an order for Ondansetron HCL 4 mg tablet, take one tablet (4mg) by mouth every six hours as needed for nausea and vomiting, start date 8/28/2025.  During a concurrent interview and record review on 12/18/2025 at 9:34 a.m., with Register Nurse Case Manager (RNCM) 2, Patient 6’s “Initial Comprehensive Assessment Encounter” dated 8/29/2025 and POC dated 12/15/2025 were reviewed. RNCM 2 stated Patient 6 had orders for NPO, medications to be given orally and via g-tube. RNCM 2 stated the Skilled Nursing Facility (SNF) where Patient 6 was receiving care had orders for medications to be given via g-tube only and that Patient 6 did not receive oral medications. RNCM 2 stated he overlooked the orders and that Patient 6 should not have medications to be given orally. RNCM 2 stated taking oral medications could put Patient 6 in danger. RNCM 2 stated it was his responsibility to oversee and verify the orders placed.   During an interview on 12/18/2025 at 10:45 a.m. with Physician 1, Physician 1 stated Patient 6 had a diagnosis of dysphagia and protrusion of the tongue which would make it unsafe for Patient 6 to take any medication or food by mouth. Physician 1 stated she had a face-to-face with Patient 6 and SNF staff on 12/18/2025 and verified medication orders and that Patient 6 was only taking medication via g-tube. Physician 1 stated Patient 6 can asphyxiate if given medication or food orally.  Physician 1 stated she “overlooked” Patient 6 orders that needed to be reviewed, approved, and signed by her.   During a review of HA Policy & Procedure (P&P) titled “Initial and Comprehensive Assessment”, dated 12/8/2025, P&P indicated the following:  Initial Comprehensive assessment RN overview consists of: RN initial comprehensive assessment encounter and POC   Updated comprehensive assessment demonstrates that all members of the interdisciplinary team (IDG) are actively involved in evaluating the patient's care including: identification of the care and needs of the patient based on assessment; ongoing assessment and monitoring of symptoms; provision of care plan interventions; recent accurate information about the patient/family to identify when changes to the POC are needed.    During a review of the Hospice Agency’s policy and procedure (P&P) titled, “Pharmacy Process,” (undated), the P&P indicated the following:     “Nursing Visit Pharmacological Overview: ensure medication bottles with labels or medication list is at the location of care... Each Nursing Updated Comprehensive Assessment Visits begins with a review of the patient’s Plan of Care (POC) which included current medications... Complete and document patient assessment including... availability of medications. Monitor medication amounts every visit, and order refills to ensure adequate supply in place until next visit... Assess for medication adverse event (an undesired effect of a drug or other type of treatment,) ... Ensure that the pharmacological orders are transcribed onto all appropriate places... update the POC.”     “The Chart Medication List should be reviewed during each patient visit and during Interdisciplinary Group to ensure it is up to date including active and discontinued medications.”      “Pharmacy Oversight Completed by Physician: prescribed, over the counter, herbal, and alternate medications that could affect drug therapy are reviewed by the physician to include effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring... If any medication issues are identified the physician should utilize the pharmacy or pharmacist as a resource.”

Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial & Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) of patient was met as follows:  The HA failed to complete an initial certification of terminal illness for transferred patients from prior hospice to current hospice for two (2) of 19 sampled patients (Patient 2 and Patient 3). --- This failure had the potential to result in the patient receiving services that were insufficient or inappropriate for their current condition, adversely affecting end-of-life outcomes. (Refer to L667).  The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of Patient to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits.

Based on interview and record review, the HA (Hospice Agency – a team of healthcare professionals that provides specialized, comfort-focused care for people with terminal illnesses who have roughly six months or less to live) failed to complete an initial certification of terminal illness (CTI – the first diagnosis or medical condition that a doctor confirms is likely to cause a person’s death within six months) for transferred patients from prior hospice to current hospice for two of 19 sampled patients (Patient 2 and Patient 3).    This failure had the potential to result in the patient receiving services that were insufficient or inappropriate for their current condition and may compromise the quality of the final days by failing to meet the requirements for peaceful passing.    On 12/19/2025, at 1:51 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the Hospice Agency’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Vice President of Operations (VPO) and National Patient Care Administrator (NPCA) 2, for failure to complete CTI for transferred patients from prior hospice for two of 19 sampled patients, Patient 2 and Patient 3. This failure had the potential to result in the patient receiving services that were insufficient or inappropriate for their current condition and may compromise the quality of the final days by failing to meet the requirements for peaceful passing.     On 12/19/2025 at 4:52 p.m., the HA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely).    On 12/19/2025, at 5:04 p.m., the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the VPO, NPCA 2, Administrator and virtual attendees NPCA 1, Senior Vice President of Operations (SVPO) 1 and SVPO 2, with the IJ situations not removed.   On 12/29/2025 at 2:22 p.m., the agency submitted an acceptable IJ removal plan, was reviewed and accepted.   On 12/29/2025, the survey team conducted an onsite visit to the agency and verified the IJ implementation. The IJ was removed on 12/29/2025 at 4:10 p.m., in the presence of the Administrator. --- Findings:    1. During a review of Patient 2’s “Case Sheet,” (page of the medical chart containing a summary of basic patient information) dated 9/8/2025, the “Case Sheet” indicated the Hospice Agency admitted Patient 2 on 9/6/2025 with diagnoses including severe protein-calorie malnutrition (when an individual does not consume sufficient amounts of both protein and calories [unit of energy to express nutritional value of foods] necessary for maintaining health and bodily function) and dementia (a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life), psychotic  (a person has lost touch with reality, experiencing symptoms like hearing voices or having false beliefs that aren’t there) disturbance, mood disturbance, and anxiety (a feeling of worry, nervousness, or unease, typically about an eminent event or something with an uncertain outcome).     During a review of Patient 2’s “CTI (Certification of Terminal Illness) - Physician’s Certification for Hospice Benefit (a Physician certifies in writing that a patient has a terminal illness with a life expectancy of six months or less and they’ve chosen comfort care over cure-focused treatment),” for certification period of 9/3/2025 to 12/1/2025, the “CTI - Physician’s Certification for Hospice Benefit” indicated the CTI form belongs to hospice agency 2, “Medical Director Attestation/Certification. I attest that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient,” was signed by a physician from hospice agency 2.     During a concurrent interview and record review, on 12/15/2025 at 3:00 p.m., with National Patient Care Administrator (NPCA 2), NPCA 2 stated Patient 2 was transferred from hospice agency 2 to hospice agency 1 and hospice agency 1 did not complete a CTI and that the CTI from hospice agency 2 was used instead when Patient 2 was admitted to hospice agency 1.    During a concurrent interview and record review on 12/19/2025 at 9:39 a.m., with hospice agency 1’s Medical Director (MD) 1 and the MD 1 stated that for every patient admitted to hospice agency 1, including transfer from prior hospice agency, should have a CTI from hospice agency 1’s physician. The MD 1 stated completing a CTI for patients transferred from another hospice agency was important to ensure that the patient remained eligible for hospice care and that they receive sufficient and appropriate services based on the Registered Nurse’s initial assessment, history and physical, and notes from prior hospice agency and that the final decision would be on MD 1 , if the patient is eligible for hospice. The MD stated that Patient 2 did not have a CTI completed by HA 1 for certification period of 9/6/2025 to 12/1/2025 and thought that hospice agency 1 was doing it because that was their process; however, she could see that it was not being done and needed to be implemented right away.   During a review of the Hospice Agency’s policy and procedure (P&P) titled “VS ([hospice agency 1’s Company Name] Standard) Cert Recert,” (undated), the P&P indicated for initial certification:   Initial certification is for benefit period one. It might not be period one if the patient has used the benefit before current admission.   Each subsequent certification is a recertification.   Initial and Recertification Documentation and Attending Initial Certification may include admission orders, hospice initial certification and attending initial certification, physician narrative addendums (initial and recertification), face-to-face encounter, and plan of care review (POCR) for recertification and addendum: POCR recert note.    Hospice physician shall determine eligibility for hospice care based on pre-admission evaluation, terminal diagnosis (a doctor has identified an illness that is incurable, cannot be cured, and is expected to lead to death) , objective and subjective clinical findings, information from face-to-face visits, input from attending or other training physicians, information from other relevant sources.    Hospice physician shall complete the appropriate documentation: dictated narrative addendum to Initial Certification and Dictated face-to-face. If acting as the attending physician, the hospice physician shall sign the Initial Certification Form or the Admission Orders, and the physician must both sign and document the date of the Initial Certification Form or Admission Orders in his/her own handwriting.   2. During a review of Patient 3’s “Case Sheet,” dated 12/11/2025, the “Case Sheet” indicated hospice agency 1 admitted Patient 3 on 10/13/2025, with diagnoses that included malignant neoplasm of head of pancreas (aggressive tumor in the pancreas [organ that aides in digestion and blood sugar control] that grows uncontrollably, interfering with normal functions) and hypertension (HTN, high blood pressure).      During a review of Patient 3’s “Change in Designation of Hospice,” dated 10/13/2025, indicated Patient 3 transferred from HA 3 to HA 1 on 10/13/2025.    During a review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated 8/21/2025, the “Physician Certification for Hospice Benefit” indicated HA 3’s company name in the top left corner, indicating the form belonged to HA 3. The “Physician Certification for Hospice Benefit” indicated the form was authored and signed by a physician from HA 3 and indicated, “Medical Director Attestation/Certification: I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient” for certification period 8/24/2025 to 10/22/2025.    During an interview on 12/19/2025 at 8:59 a.m., with HA 1’s NPCA 2, NPCA 2 stated that Patient 3 transferred from HA 3 to HA 1 on 10/13/2025, during the fourth benefit period (8/24/2025 – 10/22/2025) with 10 days remaining. NPCA 2 stated that HA 1 did not complete a CTI when Patient 3 was admitted to HA 1. NPCA 2 stated Patient 3’s CTI from HA 3 was used as the patient’s CTI for HA 1.  NPCA 2 stated when a patient was transferred from one hospice to another hospice, it is considered a new admission.    During an interview on 12/19/2025 at 9:39 a.m. with HA 1’s Medical Director (MD) 1, MD 1 stated “new admission” meant the first day a patient was admitted to HA 1, even if the patient had been previously admitted or if the patient transferred from another Hospice Agency. The MD 1 stated all patients admitted to HA 1 should have a CTI authored and signed by the physicians employed or contracted by HA 1. The MD 1 stated that the certifying physician makes the ultimate decision regarding a patient’s hospice benefit eligibility. MD 1 stated that HA 1’s physician and the registered nurse (RN) must conduct their own patient assessment at the time of the patient’s admission. The MD 1 stated the patient’s medical record from another HA could be obtained however, HA 1’s physician must conduct the CTI upon the patient’s admission.    During a concurrent interview and record review on 12/19/2025 at 10:05 a.m., with MD 1, Patient 3’s “Physician’s Certification for Hospice Benefit,” dated 8/21/2025 was reviewed. The “Physician’s Certification for Hospice Benefit” indicated that Patient 3 was determined to be eligible for hospice benefit by a physician from HA 3. MD 1 stated the CTI form was completed by HA 3 and not HA 1. MD 1 stated that HA 1 should have completed the form titled “[HA 1 company name] Hospice Initial Certification of Terminal Illness” for the date of admission through the remaining days in benefit period #4 (10/13/2025 – 10/22/2025).   During a review of the HA's P&P titled “Standard Cert (Certification) Recert (Recertification),” (undated), the P&P indicated for initial certification:   Initial certification is for benefit period one. It might not be period one if the patient has used the benefit before current admission. Each subsequent certification is a recertification.  Initial and Recertification Documentation and Attending Initial Certification may include admission orders, hospice initial certification and attending initial certification, physician narrative addendums (initial and recertification), face-to-face encounter, and plan of care review (POCR) for recertification and addendum: POCR recert note. Hospice physician shall determine eligibility for hospice care based on pre-admission evaluation, terminal diagnosis, objective and subjective clinical findings, information from face-to-face visits, input from attending or other training physicians, information from other relevant sources.  Hospice physician shall complete the appropriate documentation: dictated narrative addendum to Initial Certification and Dictated face-to-face. If acting as the attending physician, the hospice physician shall sign the Initial Certification Form or the Admission Orders, and the physician must both sign and document the date of the Initial Certification Form or Admission Orders in his/her own handwriting.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: --- --The hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the patient has the right to receive appropriate care and treatment promptly for one of nineteen sampled patients (Patient 12) with Wounds/Integumentary (Skin or bodys outer layer) skin breakdown. This deficient practice resulted in the delayed provision of wound care treatment and intervention that could lead to wound infection and serious complications. Refer to L517. The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated (written law) compliance with Federal regulations for Patients Rights to ensure their rights are not violated and receive the highest quality of hospice care. 1--The hospice agency failed to ensure that the hospice admissions nurse ordered the required pain and anti-seizure medication for one of nineteen sampled patients (Patient 1) during the pre-admission evaluation prior to Patient 1s transfer to the long-term facility for pain management. This deficient practice resulted in Patient 1 not having pain and anti-seizure medication for several hours. (Refer to L512)

Based on observation, interview and record review, the Hospice Agency ( HA- a program of care for people who are terminally ill(patients who have 6 months or less to live) and their families that focuses on comfort and quality of life) failed to ensure the hospice admissions nurse ordered and delivered the required pain and anti-seizure medications (medications used to treat seizures and other conditions by controlling abnormal brain activity) during the pre-admission evaluation for one of nineteen sampled patients (Patient 1) prior to Patient 1s transfer to the long-term facility for pain and seizure management. This deficient practice resulted in Patient 1 not having pain and anti-seizure medication for several hours and violation of patient's rights to receive appropriate pain and anti-seizure management treatment. --- A complaint validation survey (a type of survey conducted by the Centers for Medicare & Medicaid Services (CMS) to investigate allegations of noncompliance with Medicare to assess the ability of an accredited provider or supplier to comply with Medicare conditions) was conducted at this agency location on 11/5/2024 to 11/8/2024. During a review on 11/5/2024 at 11:10 a.m., indicated that Patient 1s complaint was listed and initiated by the former Patient Care Administrator indicating that an ";RN arrived to facility to complete initial comprehensive assessment (ICA) and received patient in pain. No pain medication was available upon SN (skilled nurse) arrival. A review on Patient 1s document titled "; Case Sheet" showed that Patient 1 was admitted to the hospice agency on 2/2/2024 with a diagnosis of sepsis (a life-threatening medical emergency that occurs when the body's immune system overreacts to an infection or injury) and conversion disorder with seizures (a mental health condition where a person experiences seizure-like episodes, often appearing similar to epileptic seizures, but originating from psychological stress rather than neurological abnormalities). A review of Patient 1s document titled ";History and Physical" authored by the hospice agencys medical director (MD) and signed on 2/12/2024, MD wrote that Patient 1s history of present illness indicated the patient was currently referred from acute hospital with a complicated history that began in July 2023. Patient 1 presented with altered mental status at the acute hospital and subsequently had 3 craniotomies (a surgical procedure that involves removing a portion of the skull to access the brain) including a brain biopsy (study of a tissue of the brain) that revealed herpes simplex virus 1(a common virus that causes blisters in a part of the body). Patient 1 sustained an intracerebral hemorrhage (bleeding from the brain) followed by complications of hydrocephalus (enlargement of the brain due to increase in fluid) requiring the placement of external ventricular drain (EVD, a medical device that's used to drain excess fluid from the brain's ventricles). Patient 1 developed pseudo meningocele ( a collection of fluid in the brain) and her CSF( cerebrospinal fluid- the fluid that flows in the spinal cord) cultures grew out Candida parapsilosis (a type of fungus that lives in the body) and was treated with intravenous (IV- thru the vein) Amphotericin and Flucytosine ( types of antifungal medication) She developed seizure disorder (a sudden burst of electrical activity in the brain. It can cause changes in behavior, involuntary movements and feelings) right-sided hemiparesis (right side of the body that cannot move or function), and aphasia (a language disorder that makes it hard to communicate) and had a rocky course. Her pain was managed with IV( intravenous- meaning medications administered thru the vein) Dilaudid (a kind of pain medication) with significant functional and cognitive decline, requiring aggressive comfort and palliative care measures under the direction of this hospice under a high level of care (GIP- general inpatient care- a short-term level of hospice care for patients who need acute symptom control or pain management that can't be managed in other settings). During a review on 11/6/2024 at 9 a.m., of Patient 1s document titled ";RN Initial Comprehensive Assessment (ICA- a detailed evaluation of a patient's health, needs, and condition) dated 2/2/2024 indicated that the RN 1 arrived on 2/2/2024 at the skilled nursing facility (SNF) at 7:18 p.m., to conduct the initial comprehensive assessment. RN 1 documented that the Patient 1's family member expressed concern that the patient has IV Dilaudid due at 6 p.m. RN 1 wrote that the Patient 1s level of pain was 8/10 (indicated severe pain). RN 1 further documented that during the initial comprehensive assessment, the patient suffered multiple short-lived seizures during her visit. RN 1 wrote ";meds pending order to facility pharmacy-local pharmacy order obtained and pending delivery." During a review of RN 1's "Focus Visit" document dated 2/3/2024 indicated that the first pain medication dose of Dilaudid 2 mg 1 tablet one time dose for pain and Lorazepam 0.5 mg one time dose given at 12:34 a.m.. RN 1 documented at "1:00 a.m., new order for Lorazepam 2 mg every 15 minutes for seizure. At 1:15 p.m., second dose of Lorazepam 2 mg given. RN 1 wrote at ";2:00 a.m., delivery of IV Dilaudid arrived, set up attempted but pump (the machine that would deliver the intravenous pain medication) was defective. Called pharmacy for trouble shooting, unable to resolve. Pharmacy to send new pump. Unable to confirm expected time of arrival." At 4:40 a.m., RN 1 left the facility and endorsed follow up to Telecare (agencys after-hours hotline). During an interview with the Regional Director for Admissions (RDA) on 11/7/2024 at 2:15 p.m., RDA stated that the hospice agency uses a form called the Pre-Admission Evaluation (PAE- a data collection tool used by admission nurses). RDA stated that there was no skin and other bodily assessments in the Pre-Admission Evaluation. RDA stated that the admission nurses only write the information on the form as stated by the patient's family or any available medical records at the patient's location. During an interview on 11/8/2024 at 12:31 p.m., with the agency's Director of Admissions, stated that the admission nurse assigned to conduct the pre-admission evaluation collects pertinent data required for the admission such as signing consents, gathering medical history and list of current medications and medical equipment needed. Director of Admissions also stated that after confirming with the doctor, the admission nurse will order the medications from the pharmacy and the pharmacy sends it to the patient's location. Director of Admissions further stated that in Patient 1's case, the medications should have been ordered thru the long-term facility pharmacy or the nearest 24-hour pharmacy closest to the patient's location. Director of Admissions also stated that the admission nurses order the medical equipment and medications prior to arriving at the patient's current location. A review of the hospice agencys document titled ";VS LTC Long Term Care Facility Coordination of Care" page 169 updated 6/6/2024 indicated, the hospice must develop and maintain a system of communication and integration, in accordance with the hospices own policies and procedures, to (i) Ensure that the interdisciplinary group maintains responsibility for directing, coordinating and supervising the care and services provided, (ii). Ensure that the care and services are provided in accordance with the plan of care (iii). Ensure that the care and services provided are based on all assessments of the patient and family needs, (iv). Provide and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, (v). Provide an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. A review of the hospice agencys document titled ";Hospice Services Agreement" dated 9/1/2023 indicated Exhibit E: Designation of Hospice and Facility Roles and Responsibilities indicated that determines manner in which services will be controlled, coordinated and evaluated, coordinates, supervises and evaluates care being delivered/continuity, determines services to be provided, development of plan of care, including medical direction. Reviews and revise plan of care, provides input as requested by Hospice are all responsibilities of the hospice agency. A review of the hospice agency's document titled "VS Patient Rights" page 199 indicated, 2. Rights of the Patient: 3. Patients will receive effective pain management and symptom control for conditions related to terminal illness.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the patient has the right to receive appropriate care and treatment promptly for one of nineteen sampled patients (Patient 12) with Wounds/Integumentary (Skin or bodys outer layer) skin breakdown. This deficient practice resulted in the delayed provision of wound care treatment and intervention that could lead to wound infection and complications. --- During a review of Patient 12s ";Case Sheet," indicated Patient 12 was admitted to the HA on 11/17/2023 with a terminal diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 12s ";Addendum Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) Review/Recert Note," dated 8/28/2024, the Addendum POC Review/Recert Note indicated the nurse visit frequency of once a week for recertification period from 9/12/2024 to 11/11/2024. During a review of Patient 12s ";RN (Registered Nurse) Initial Comprehensive Assessment," dated 11/18/2023, the RN Initial Comprehensive Assessment indicated in the ";Wounds/Integumentary (Skin or bodys outer layer)" section was marked Check for ";Assessed, no Integumentary Symptoms identified – NA (Not Applicable." During a joint home visit observation, and interview on 11/6/2024 at 12:25 p.m., with Registered Nurse 3 (RN 3) at Patient 12s residence, Patient 12 was observed lying in bed, awake and oriented to her name only. RN 3 stated he had seen Patient 12 yesterday. Patient 12 resides in a board and care (licensed residential home for long term care individuals) setting, and the House Manager (HM), who acted as her primary caregiver, was present during the visit. Both RN 3 and HM confirmed and stated that Patient 12 has no existing wounds. RN 3 conducted a skin assessment on Patient 12. Patient 12 was observed with a band aid (a piece of sticking plaster with pad in the center, used to cover wound) covering Patient 12s middle area of right lateral foot. RN3 removed the band aid. Patient 12 had a skin abnormality that appeared as having a necrotic (dead) tissue, black in color in the center area, round, small amount of yellow discharge, yellow slough (dead skin shedding), redness/slight swelling to surrounding area and measured approximately less than two centimeters (cm) in width and length. RN 3 stated that he came to see Patient 12 yesterday (11/5/2024), RN 1 stated that he missed to conduct a thorough head to toe assessment with Patient 12. RN 3 stated that Patient 12s skin abnormality appeared to be a skin tear and could also be a stage 2 pressure injury (characterized as open wounds, skin breaks open, wears away, or forms an ulcer, which is usually tender and painful, the wound expands into deeper layers of the skin and can look like a scrape (abrasion), blister, or a shallow crater in the skin), RN 3 stated that the center area of the wound, when he palpated was hard, has black in color in the center area, round, had a small amount of yellow discharge, yellow slough (dead skin shedding), redness/slight swelling to the surrounding area. RN 3 measured the wound with approximately less than two centimeters (cm) in width and length. Patient 12 retracted Patient 12 right foot when RN 3 gently palpated the wound located at right lateral foot. RN 3 stated that it could be a pressure injury since Patient 12 was immobile and bed bound. RN 3 stated that he did not know when Patient 12 had the wound on the right lateral foot. RN 3 confirmed and stated that there was no current wound treatment for Patient 12s wound on right lateral foot. RN 3 stated that it was important to conduct a skin assessment for patient every visit, to identify any presence of wounds and to have it communicated to the physician to obtain a wound treatment orders and care plan. RN 3 stated that he had no documentation of skin assessment particularly to Patient 12s wound on right lateral foot since he did not identify it. RN 3 stated that not identifying and providing appropriate treatment to Patient 12s wound could result in infection and worsening condition. During an interview with HM at 11:55 a.m., HM stated that Patient 12 had scab on her right lateral foot for months. HM stated that she reported it to the visiting nurses and was told that the HA was going to send supplies for the wound treatment. HM stated that she told the visiting nurses twice around September 2024 and October 2024. HM stated that Patient 12 was unable to reposition herself and was totally dependent. HM stated she repositioned the patient frequently every 2 hours as she was thin and susceptible to develop pressure injury. HM stated that there was no current wound treatment done to Patient 12s wound on her right lateral foot and it looked worse than before HM confirmed and stated that RN 3 came yesterday (11/5/2024) and visited Patient 12 but did not gave him any instructions regarding wound treatment of Patient 12s wound on right lateral foot. During an interview and concurrent record review of Patient 12s clinical record on 11/7/2024, at 10:30 a.m., with the Patient Care Administrator (PCA) and National Patient Care Administrator (RN4) disclosed the following: --Patient 12s clinical record titled ";Interdisciplinary (ID, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Plan of Care (POC)Revision/Physician Orders," dated 10/2/2024, the ID POC Revision/Physician Orders indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation of Patient 12s wound on right lateral foot. --Patient 12s clinical record titled ";Plan of Care (POC) Review for Recertification," dated 8/28/2024, the POC Review for Recertification indicated on section ";Response to Care and Updates to Comprehensive Assessment" on area of ";Integumentary" was left blank with no documentation. RN4 and PCA both confirmed and stated that there was no clinical documentation of Patient 12s wound on right lateral foot. RN4 stated that it was left bank since there was no problem or area of concern on Patient 12 s skin integrity. --Patient 12s clinical record titled ";Plan of Care (POC) Review," dated 8/14/2024, 8/28/2024 and 9/24/2024, the POC review indicated on section ";Response to Care and Updates to Comprehensive Assessment" on area of ";Integumentary" was left blank with no documentation for the dates of 8/14/2024 and 8/28/2024, and for the date of 9/24/2024, on area of ";Integumentary" with documentation of ";skin intact." RN4 and PCA both confirmed and stated that there was no clinical documentation of Patient 12s wound on right lateral foot. RN4 stated that section ";Integumentary" was left bank since there was no problem or area of concern on Patient 12 s skin integrity. -Patient 12s clinical record titled ";Focus Visit," dated 8/27/2024 and 8/29/2024, the Focus Visit indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation of Patient 12s wound on right lateral foot. RN 4 stated that Focus Visit was completed by the visiting nurses. -Patient 12s clinical record titled ";Nursing-Updated Comprehensive Assessment," dated 9/5/2024, 9/15/2024, 9/24/2024, 10/2/2024, 10/16/2024 and 10/29/2024, the Nursing-Updated Comprehensive Assessment indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated there was no clinical documentation of Patient 12s wound on right lateral foot. RN 4 stated that if Patient 12s wound on right lateral foot is located on the pressure spot then it could be a pressure injury, RN 4 stated it looks like unstageable and the lateral side of the right foot can be a pressure spot, RN 4 stated that it appeared like sloughing and not a purulent discharge but the redness on the surrounding area and discoloration are present and could be a skin breakdown on surface of the wound. RN 4 stated that visiting nurse should contact the physician and obtain wound care orders. RN 4 stated that the visiting nurse that identified the patients wound should conduct a complete assessment of wound that included the measurement, description, location, and characteristics that would reflect to patients clinical records. RN 4 stated that after patients wound was assessed, it must have care plan, obtain a treatment order from the physician, and discuss it with the ID team. RN 4 stated that potential outcome, if patients wound not treated, will result in further skin breakdown, infection, sepsis, that could lead to hospitalization. Both PCA and RN 4 stated that HA did not have any evidence of skin assessments, wound treatments and plan of care in relation to Patient 12s wound on right lateral foot. --Patient 12s clinical record titled ";Medication List," dated 10/31/2024, the Medication List indicated no wound treatment orders for Patient 12s wound on right lateral foot. Both PCA and RN 4 confirmed that there was no current wound treatment order for Patient 12s wound on right lateral foot and stated that if there was a current order, it should appear in Patient 12s medication list. RN 4 stated that Patient 12s wound should have a a treatment order to provide appropriate care for the wound and to prevent it from getting infected that could lead to worsening condition. During an interview on 11/7/2024, at 1:16 p.m., with the HAs Medical Director (MD), the MD reviewed picture of Patient 12s wound on the right lateral foot and stated that Patient 12s wound on the right lateral foot could be infected due to erythema (abnormal redness of the skin due to inflammation) and contained what appeared to be a small amount of purulent (thick milky or yellow discharge that comes out from the wound) or sloughing (dead skin shedding). MD stated that Patient 12s wound from the right lateral foot could be from abrasion or pressure injury, or combination of both. MD stated that he was not notified since yesterday (11/6/2024) or even before regarding Patient 12s wound condition on right lateral foot. MD stated that he cannot remember if he got notified by any clinical staff regarding Patient 12s wound on right lateral foot. MD stated that Patient 12 is susceptible to develop pressure injury due to her being a bedbound, wheelchair bound and immobile. MD stated that Patient 12s wound on the right lateral foot would need a wound treatment to prevent it from getting worse and infected. During a review of the HAs policy and procedure (P&P) titled, ";Patient Rights," updated 10/11/2023, the P&P indicated, ";The patient has the right to the following: (6) Be free from mistreatment, neglect or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) of the patient was met as follows: --- 1. Ensure the licensed nurses (in general) assessed the patients skin condition and updated the comprehensive assessment of one of 19 sampled patients (Patient 12) that reflected the open skin wound (unidentified) located in Patient 12's right lateral (side) foot. As a result, the non-compliance resulted in Patient 12s open (unidentified) skin wound located in Patient 12's right lateral (side) foot left untreated that could lead to experience pain, worsening of the skin wound including infection, sepsis (is the bodys overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death) potential hospitalization, and death. (Refer to L 533). 2. The HA failed to complete the comprehensive assessment to identify the patient/familys physical, psychosocial, emotional, and spiritual needs within 5 calendar days of hospice care election for two of nineteen sampled patients (Patient 7 and Patient 8). (Refer to L523). 3. The HA staff failed to review all the medications and update the medication profile with currently used medications for three of nineteen sampled patients (Patient 1, Patient 7, and Patient 12). (Refer to L530). 4. The HA failed to conduct an initial bereavement assessment within five calendar days upon admission for two of nineteen sampled patients (Patient 7 and Patient 8). (Refer to L531). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to complete the comprehensive assessment to identify the patient/familys physical, psychosocial, emotional, and spiritual needs within 5 calendar days of hospice care election for two of nineteen sampled patients (Patient 7 and Patient 8). This deficient practice had the potential in the delay to create the development of the plan of care to address the patients' identified needs. --- a. A review of Patient 7s Case Sheet indicated Patient 7 was admitted on 10/31/2024 with a primary diagnosis of Alzheimers disease (a type of brain disorder that causes problems with memory, thinking and behavior), unspecified. A review of Patient 7s RN (Registered Nurse) – Initial Comprehensive Assessment, dated 11/1/2024, indicated that SW (Social Worker) Evaluation and Chaplain Evaluation boxes were checked. During a joint visit with Registered Nurse 2 (RN 2) on 11/6/2024 at 1:10 p.m., observed Patient 7 lying in bed with both eyes closed. Patient 7 responded by opening her eyes when RN 2 called her name. Patient 7 resided in Assisted Living Facility 1 (ALF 1). During an interview with RN 2 on 11/6/2024 at 2 p.m., RN 2 stated each patient had an RN Initial Comprehensive Assessment and a Psychosocial/Spiritual Initial Comprehensive Assessment. Per RN 2, both assessments were conducted upon admission, and the Social Worker or Chaplain would be the one completing the Psychosocial/Spiritual Initial Comprehensive Assessment. On 11/7/2024, during a review of Patient 7s physical chart kept at the HAs office, there was no Psychosocial/Spiritual Initial Comprehensive Assessment filed in the patients chart. During a phone interview with the Chaplain on 11/7/2024 at 12:37 p.m., the Chaplain stated, ";For new admissions, the Social Worker is the one doing the psychosocial initial comprehensive assessment. Its usually done within five days after admission. The Social Worker would inform me if the family requested a chaplain. I will do the follow-up within 48 hours." The Chaplain stated he had just seen Patient 7 that morning in Assisted Living Facility 1 (ALF 1). The Chaplain stated he did not see a psychosocial initial comprehensive assessment completed for Patient 7, so he did not think the SW had seen and evaluated Patient 7. The Chaplain also stated that if the Social Worker (SW) was unavailable to do the psychosocial initial comprehensive assessment, he would be notified, so that he could conduct the psychosocial initial comprehensive assessment. When asked if he was informed to conduct the psychosocial initial comprehensive assessment for Patient 7, the Chaplain said he did not. During a phone interview with the SW on 11/7/2024 at 12:57 p.m., the SW stated the psychosocial initial comprehensive assessment for newly admitted patients was done by the SW and the Chaplain was the back up. The SW stated she had not completed the psychosocial initial comprehensive assessment for Patient 7 because she was off when Patient 7 was admitted. The SW stated she was not sure if the Chaplain had done the psychosocial initial comprehensive assessment. The SW stated it was important to complete the psychosocial initial comprehensive assessment within 5 calendar days after admission, so that the patients and/or familys coping skills, resources available, advance directives could be assessed, and the HA could provide the appropriate support. b. A review of Patient 8s Case Sheet indicated Patient 8 was admitted on 6/14/2024 with a primary diagnosis of Alzheimers disease (a type of brain disorder that causes problems with memory, thinking and behavior), unspecified. A review of Patient 8s RN– Initial Comprehensive Assessment, indicated the assessment was completed on 6/15/2024. A review of Patient 8s Psychosocial/Spiritual– Initial Comprehensive Assessment, indicated the assessment was completed on 6/24/2024, which was more than 5 calendar days after admission. During a concurrent record review and interview with the Patient Care Administrator (PCA) on 11/7/2024 at 1:40 p.m., the PCA stated that Psychosocial/Spiritual– Initial Comprehensive Assessment was part of the comprehensive assessment; the other part was the RN – Initial Comprehensive Assessment, which was completed by the RN. The PCA stated the timeframe to complete the initial comprehensive assessment was five calendar days after the election of hospice. The PCA stated she did not know why the Psychosocial/Spiritual– Initial Comprehensive Assessment for Patient 8 was done ten days after admission, as she had only been working for the HA for the past three months. The PCA stated she did not see any communication note regarding the delay. The PCA stated the psychosocial/spiritual initial comprehensive assessment needed to be completed within five calendar days in order to assess the patient and familys psychosocial, emotional, and spiritual needs, and to assist in creating the plan of care. A review of the HAs policy and procedure, titled ";VS Initial and Comprehensive Assessment," undated, indicated the hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services, and the patients need for physical, psychosocial, emotional, and spiritual care. The hospice interdisciplinary group, in consultation with the individuals attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) staff failed to review all the medications and update the medication profiles with currently used medications for two of nineteen sampled patients (Patient 7 and Patient 12). This deficient practice has the potential to result in medications errors and adverse drug reactions that could affect the patients' health status and well-being. --- A review of Patient 7s Case Sheet indicated Patient 7 was admitted on 10/31/2024 with a primary diagnosis of Alzheimers disease (a type of brain disorder that causes problems with memory, thinking and behavior), unspecified. A review of Patient 7s Interdisciplinary Care Plan (a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 10/31/2024, indicated the interventions for Patient 7 included medications (drug interactions/treatment indications, use, and side effects). During a joint visit with Registered Nurse 2 (RN 2) on 11/6/2024 at 1:10 p.m., observed Patient 7 lying in bed with both eyes closed. Patient 7 responded by opening her eyes when RN 2 called her name. Patient 7 resided in Assisted Living Facility 1 (ALF 1). During the joint visit, a medication review was conducted with RN 2 and Licensed Vocational Nurse 2 (LVN 2). LVN 2 is a nursing staff employed by ALF 1 and was assigned to Patient 7. A review of Patient 7s Chart Medication List/Signed Physician Orders, printed on 11/5/2024, indicated that Zofran (a medication that prevents nausea and vomiting caused by chemotherapy, radiation, or surgery) 4 Mg (a measurement unit) tablet was ordered for Patient 7. The instruction for Zofran 4 mg was as follows: Take one tablet (4 Mg) by mouth every four hours as needed for nausea and/or vomiting. Upon medication review on, LVN 2 stated that Patient 7 did not have an order for Zofran 4 Mg, therefore Zofran 4 mg was not available. A review of Patient 7s Physicians Orders, provided by LVN 2, did not list Zofran 4 Mg as one of the medications ordered for Patient 7. LVN 2 stated all medications ordered by Patient 7s physicians, including the HAs physician, would be listed on it. During a concurrent record review and interview with RN 2 on 11/6/2024 at 1:50 p.m., RN 2 confirmed that Zofran 4 Mg was not listed on Patient 7s Physicians Orders maintained by ALF 1. RN 2 stated that Zofran 4 Mg was ordered by the HAs physician as part of the comfort kit, but somehow it did not get transcribed to the ALF 1s Physicians Orders. Patient 7 was newly admitted on 10/31/2024, and she had only visited Patient 7 once. RN 2 stated she was going to coordinate with ALF 1 and the pharmacy to ensure availability of Zofran 4 Mg. During a concurrent record review and interview with the Patient Care administrator (PCA) on 11/7/2024 at 1:20 p.m., the PCA reviewed Patient 7s Chart Medication List/Signed Physician Orders and Physicians Orders maintained by ALF 1. The PCA stated all orders in the Chart Medication List/Signed Physician Orders were supposed to be transcribed to the Physicians Orders. According to the PCA, full medication reconciliation needed to be done upon admission, and the HAs Medical Director or the patients attending physician would review the medications. The PCA stated for patients residing in a facility, the HAs staff needed to maintain communication with the facilitys staff to ensure they were on the same page. The PCA also stated that medication reconciliation was to be conducted with every visit. A review of the HAs policy and procedure, titled ";VS Pharmacy Process," undated, indicated the HAs nurse was responsible for medication reconciliation (the process of identifying the most accurate list of all medications the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider). During a review of Patient 12s ";Case Sheet," the Case Sheet indicated Patient 12 was admitted to the HA on 11/17/2023 with a terminal diagnosis of ";Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior)." During a review of Patient 12s ";Addendum Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) Review/Recert Note," dated 8/28/2024, indicated that Patient 12's nurse visit frequency of once a week for recertification period from 9/12/2024 to 11/11/2024. During a joint home visit observation, and interview on 11/6/2024, at 12:25 p.m., with Registered Nurse 3 (RN 3) to Patient 12s residence, Patient 12 was observed lying in bed, awake and oriented to her name only. RN 3 stated he had seen Patient 12 yesterday. Patient 12 resides in a board and care (licensed residential home for long term care individuals) setting, and the House Manager (HM), who acted as her primary caregiver, was observing the visit. During Patient 12s medication review with RN3 and comparison with the medication profile, the following medications had expired dates: 1. Ibuprofen 400 milligrams (mg, unit of measurement) tablet – take one (1) tablet by mouth every six (6) hours as needed for pain. Not To Exceed (NTE) four (4) tablets/twenty-four (24) hours, with an expiration date of 6/30/2024. 2. Acetaminophen 500 mg tablet – take 1 tablet by mouth every 6 hours as needed for pain. NTE 4 doses/24 hours, with an expiration date of 6/18/2024. 3. Norco 5mg/325mg tablet – take 1 tablet by mouth every 6 hours as needed for pain, with an expiration date of 9/23/2024. 4. Hyoscyamine 0.125 mg tablet Sublingual (SL, under the tongue) – take 1 tablet by mouth under the tongue every 4 hours as needed for excess secretions. NTE 6 tablets/24 hours, with an expiration date of 5/16/2024. During an interview with RN 3 at 1 p.m., RN 3 confirmed that Ibuprofen, Acetaminophen, Norco and Hyoscyamine medications had expired. RN 3 stated he was not aware that there were some expired medications of Patient 12s medications. RN 3 stated medication reconciliation was done every nurse visit and if there were any changes or expired medications, HM should notify the agency. RN 3 stated he conducted medication reconciliation each visit but missed to check Patient 12s expired medications. RN 3 stated that it was important for a patient to not take expired medications since it could be contraindicated, not beneficial to patient due to decreased efficacy and affects patients safety. HM stated she was not aware about the expiration date of the pain medications since Patient 12 has the same unexpired medications on stock and will use it. During an interview on 11/7/2024, at 10:48 a.m., with the National Patient Care Administrator (RN 4), RN 4 stated that visiting nurses should conduct medication reconciliation each visit to determine and monitor expired or discontinued medications to prevent possible medication errors and to update the patients active medication list. RN 4 stated that administering expired medications to patient would not be beneficial and will result to decrease therapeutic effect and ineffective intervention.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to conduct an initial bereavement assessment within five calendar days upon admission for two of nineteen sampled patients (Patient 7 and Patient 8). This deficient practice had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patients anticipated death. --- a. A review of Patient 7s Case Sheet indicated Patient 7 was admitted on 10/31/2024 with a primary diagnosis of Alzheimers disease (a type of brain disorder that causes problems with memory, thinking and behavior), unspecified. A review of Patient 7s RN (Registered Nurse) – Initial Comprehensive Assessment, dated 11/1/2024, indicated that SW (Social Worker) Evaluation and Chaplain Evaluation boxes were checked. During a joint visit with Registered Nurse 2 (RN 2) on 11/6/2024 at 1:10 p.m., observed Patient 7 lying in bed with both eyes closed. Patient 7 responded by opening her eyes when RN 2 called her name. Patient 7 resided in Assisted Living Facility 1 (ALF 1). During an interview with RN 2 on 11/6/2024 at 2 p.m., RN 2 stated each patient had an RN Initial Comprehensive Assessment and a Psychosocial/Spiritual Initial Comprehensive Assessment. Per RN 2, both assessments were conducted upon admission, and the Social Worker or Chaplain would be the one completing the Psychosocial/Spiritual Initial Comprehensive Assessment. On 11/7/2024, during a review of Patient 7s physical chart kept at the HAs office, there was no Psychosocial/Spiritual Initial Comprehensive Assessment filed in the patients chart. During a phone interview with the Chaplain on 11/7/2024 at 12:37 p.m., the Chaplain stated, ";For new admissions, the Social Worker is the one doing the psychosocial initial comprehensive assessment. Its usually done within five days after admission. The Social Worker would inform me if the family requested a chaplain. I will do the follow-up within 48 hours." The Chaplain stated he had just seen Patient 7 that morning in Assisted Living Facility 1 (ALF 1). The Chaplain stated he did not see a psychosocial initial comprehensive assessment completed for Patient 7, so he did not think the SW had seen and evaluated Patient 7. The Chaplain also stated that if the Social Worker (SW) was unavailable to do the psychosocial initial comprehensive assessment, he would be notified, so that he could conduct the psychosocial initial comprehensive assessment. When asked if he was informed to conduct the psychosocial initial comprehensive assessment for Patient 7, the Chaplain said he did not. During a phone interview with the SW on 11/7/2024 at 12:57 p.m., the SW stated the psychosocial initial comprehensive assessment for newly admitted patients was done by the SW and the Chaplain was the back up. The SW stated she had not completed the psychosocial initial comprehensive assessment for Patient 7 because she was off when Patient 7 was admitted. The SW stated she was not sure if the Chaplain had done the psychosocial initial comprehensive assessment. The SW stated it was important to complete the psychosocial initial comprehensive assessment within 5 calendar days after admission, so that the patients and/or familys coping skills, resources available, advance directives could be assessed, and the HA could provide the appropriate support. b. A review of Patient 8s Case Sheet indicated Patient 8 was admitted on 6/14/2024 with a primary diagnosis of Alzheimers disease (a type of brain disorder that causes problems with memory, thinking and behavior), unspecified. A review of Patient 8s RN– Initial Comprehensive Assessment, indicated the assessment was completed on 6/15/2024. A review of Patient 8s Psychosocial/Spiritual– Initial Comprehensive Assessment, indicated the assessment was completed on 6/24/2024, which was more than 5 calendar days after admission. During a concurrent record review and interview with the Patient Care Administrator (PCA) on 11/7/2024 at 1:40 p.m., the PCA confirmed that the Psychosocial/Spiritual Initial Assessment for Patient 8 was done on 6/24/2024. The PCA stated that Psychosocial/Spiritual– Initial Comprehensive Assessment was part of the comprehensive assessment; the other part was the RN – Initial Comprehensive Assessment, which was completed by the RN. The PCA stated the timeframe to complete the initial comprehensive assessment was five calendar days after the election of hospice. The PCA stated she did not know why the Psychosocial/Spiritual– Initial Comprehensive Assessment for Patient 8 was done ten days after admission, as she had only been working for the HA for the past three months. The PCA stated she did not see any communication note regarding the delay. The PCA stated the psychosocial/spiritual initial comprehensive assessment needed to be completed within five calendar days in order to assess the patient and familys psychosocial, emotional, and spiritual needs, and to assist in creating the plan of care. A review of the HAs policy and procedure, titled ";Psychosocial/Spiritual Initial Comprehensive Assessment – High Level," dated 12/8/2023, indicated that Psychosocial/Spiritual Initial Comprehensive Assessment was to be completed by the Social Worker or Chaplain as soon as possible but no greater than 5 days after the effective date of the hospice election.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the licensed nurses (in general) assessed the patients skin condition and updated the comprehensive assessment of one of 19 sampled patients (Patient 12) that reflected the open skin wound (unidentified) located in Patient 12's right lateral (side) foot. As a result, the non-compliance resulted in Patient 12s open (unidentified) skin wound located in Patient 12's right lateral (side) foot left untreated that could lead to worsening of the skin wound including infection, sepsis (is the bodys overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death) hospitalization, and death. On 11/7/2024 at 1:43 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the hospice agency's (HA, agency providing care to terminally ill patients who has six months or less to live) Patient Care Administrator (PCA), National Patient Care Administrator (RN4) and General Manager (GM), related to failure to ensure the comprehensive assessment (an assessment used to evaluate a patients overall health, including identifying the patients need for hospice care) was updated for one of nineteen sampled patients (Patient 12) by ensuring that the licensed nurses (in general), assessed and monitored Patient 12s right lateral foot skin abnormality, ensuring the licensed nurses (in general), notified Patient 12s Medical Director (MD) of the right lateral foot skin abnormality and ensuring that the licensed nurses (in general), obtained an order to treat Patient 12s right lateral foot skin abnormality from the MD. On 11/7/2024, at 4:30 p.m., the HA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/8/2024, at 3 p.m., the survey team completed the survey tasks and conducted an exit conference, in the presence of the PCA, GM, and RN4 with the IJ situation not removed. On 12/3/2024, the survey team reviewed and accepted the IJ removal plan as follows: On 11/7/2024, Patient 12 had documentation of the right foot wound, physician notification and orders for wound care, and updated plan of care. On 11/9/2024, the physician assessed Patient 12 face to face and noted the patient with three deep tissue injuries; one in the right lateral foot. The largest is 2.5 by 1 cm, 2 additional are unstageable, and a stage II of the coccyx. She has pain requiring medications. Medications reviewed and adjusted. From 11/11/2024 to 11/18/2024, all current 132 patients were assessed. On 11/15/2024, all current six patients who had pressure injuries had an updated comprehensive assessment. On 11/15/2024, the agency's nurses were trained regarding wounds and wound care guidelines. On 12/4/2024 the survey team conducted an onsite visit and verified the agency's IJ removal plan's implementation through observation, interview, and record review, and removed the IJ situation at 1:45 pm, in the presence of RN4 and PCA (Patient Care Administration). --- Findings: During a review of Patient 12s Case Sheet, the Case Sheet indicated the HA admitted Patient 12 on 11/17/2023 with a terminal diagnosis of Alzheimers disease (is a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review of Patient 12s ";RN (Registered Nurse) Initial Comprehensive Assessment," dated 11/18/2023, the RN Initial Comprehensive Assessment indicated in the ";Wounds/Integumentary (Skin or bodys outer layer)" section was marked check for ";Assessed, no Integumentary Symptoms identified – NA (Not Applicable." During a review of Patient 12s Addendum Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) Review/Recert Note, dated 8/28/2024, the Addendum POC Review/Recert Note indicated Patient 12's nurse visit frequency of once a week, with a recertification period from 9/12/2024 to 11/11/2024. During a joint home visit observation, and interview on 11/6/2024 at 12:25 p.m., with Registered Nurse 3 (RN 3) at Patient 12s residence, Patient 12 was observed lying in bed, awake and oriented to her name. RN 3 stated he saw Patient 12 on 11/5/2024. Patient 12 resided in a board and care (licensed residential home for long term care individuals) setting, and the House Manager (HM), who acted as her primary caregiver, was observing the visit. Both RN 3 and HM confirmed and stated that Patient 12 did not have existing skin wounds. RN 3 conducted a skin assessment on Patient 12. Patient 12 had a band aid (a piece of sticking plaster with pad in the center, used to cover wound) covering Patient 12s middle area of right lateral foot. RN3 removed the band aid. RN3 stated Patient 12 had a skin abnormality that appeared as having a necrotic (dead) tissue, black in color in the center area, round, small amount of yellow discharge, yellow slough (dead skin shedding), redness/slight swelling to surrounding area and measured approximately less than two centimeters (cm) in width and length. RN 3 stated that he came to see Patient 12 yesterday (11/5/2024), RN 1 stated that he missed to conduct a thorough head to toe skin assessment with Patient 12. RN 3 stated that Patient 12s skin abnormality appeared to be a skin tear and could also be a Stage 2 pressure injury (characterized as open wounds, skin breaks open, wears away, or forms an ulcer, which is usually tender and painful, the wound expands into deeper layers of the skin and can look like a scrape (abrasion), blister, or a shallow crater in the skin), RN 3 stated that the center area of the wound, when he palpated was hard, had black in color in the center area, round, has a small amount of yellow discharge, yellow slough (dead skin shedding), redness/slight swelling to surrounding area. RN 3 measured the wound with approximately less than two centimeters (cm) in width and length. Patient 12 retracted her right foot when RN 3 gently palpated the wound located at right lateral foot. RN 3 stated that it could be a pressure injury since Patient 12 was immobile and bed bound. RN 3 stated that he did not know since when Patient 12 has her wound from right lateral foot. RN 3 stated that it was important to conduct a skin assessment for patient, on each visit, to identify for any presence of wounds and to have it communicated to the physician for any wound treatment orders and care plans. RN 3 stated that he did not have documentation of skin assessment particularly to Patient 12s wound on right lateral foot since he did not identify it. RN 3 stated that not identifying Patient 12s wound could result in infection and worsening condition if not treated. During an interview with HM at 11:55 a.m., HM stated Patient 12 had scab on her right lateral foot for months. HM stated that she reported it to the visiting nurses (unidentified)and was told that they were going to send the supplies for the wound treatment. HM stated that she told to the visiting nurses twice, around September 2024 and October 2024. HM stated that Patient 12 was unable to reposition herself and is total dependent, HM stated that she repositioned her frequently every two hours as she is thin and is susceptible to develop pressure injury. HM stated that there was no current wound treatment done to Patient 12s wound on her right lateral foot and it looked worse than before HM stated that RN 3 came yesterday (11/5/2024) and visited Patient 12 but did not gave him any instructions regarding wound treatment of Patient 12s wound on right lateral foot. During an interview and concurrent record review of Patient 12s following clinical records on 11/7/2024, at 10:30 a.m., with the Patient Care Administrator (PCA) and National Patient Care Administrator (RN4) Patient 12s clinical record titled ";Interdisciplinary (ID, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Plan of Care (POC)Revision/Physician Orders," dated 10/2/2024, the ID POC Revision/Physician Orders indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. During an interview and concurrent record review of Patient 12s following clinical records on 11/7/2024, at 10:30 a.m., with the Patient Care Administrator (PCA) and National Patient Care Administrator (RN4) Patient 12s clinical record titled ";Plan of Care (POC) Review for Recertification," dated 8/28/2024, the POC Review for Recertification indicated on section ";Response to Care and Updates to Comprehensive Assessment" on area of ";Integumentary" was left blank with no documentation. RN4 and PC stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN4 stated that it was left bank since there was no problem or area of concern on Patient 12 s skin integrity. During an interview and concurrent record review of Patient 12s following clinical records on 11/7/2024, at 10:30 a.m., with the Patient Care Administrator (PCA) and National Patient Care Administrator (RN4) Patient 12s clinical record titled ";Plan of Care (POC) Review," dated 8/14/2024, 8/28/2024 and 9/24/2024, the POC review indicated on section ";Response to Care and Updates to Comprehensive Assessment" on area of ";Integumentary" was left blank with no documentation for the dates of 8/14/2024 and 8/28/2024, and for the date of 9/24/2024, on area of ";Integumentary" with documentation of ";skin intact." RN4 and PCA both stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN4 stated that section ";Integumentary" was left bank since there was no problem or area of concern on Patient 12 s skin integrity. During an interview and concurrent record review of Patient 12s following clinical records on 11/7/2024, at 10:30 a.m., with the Patient Care Administrator (PCA) and National Patient Care Administrator (RN4) Patient 12s clinical record titled ";Focus Visit," dated 8/27/2024 and 8/29/2024, the Focus Visit indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN 4 stated that Focus Visit is completed by the visiting nurses. During an interview and concurrent record review of Patient 12s following clinical records on 11/7/2024, at 10:30 a.m., with the Patient Care Administrator (PCA) and National Patient Care Administrator (RN4) Patient 12s clinical record titled ";Nursing-Updated Comprehensive Assessment," dated 9/5/2024, 9/15/2024, 9/24/2024, 10/2/2024, 10/16/2024 and 10/29/2024, the Nursing-Updated Comprehensive Assessment indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN 4 stated that if Patient 12s wound on right lateral foot is located on the pressure spot then it could be a pressure injury, RN 4 stated it looks like unstageable and the lateral side of the right foot can be a pressure spot, RN 4 stated that it appeared like sloughing and not a purulent discharge but the redness on the surrounding area and discoloration are present and could be a skin breakdown on surface of the wound.. RN 4 stated that visiting nurse should contact the physician and obtain wound care orders. RN 4 stated that the visiting nurse that identified the patients wound should conduct a complete assessment of wound that includes the measurement, description, location, and characteristics that would reflect to patients clinical records. RN 4 stated that after patients wound was assessed, it must have care plan, obtain a treatment order from the physician, and discuss it with the ID team. RN 4 stated that potential outcome, if patients wound not treated, will result in further skin breakdown, infection, sepsis, that could lead to hospitalization. Both PCA and RN 4 stated that HA did not have any evidence of skin assessments, wound treatments and plan of care in relation to Patient 12s wound on right lateral foot. During an interview on 11/7/2024, at 1:16 p.m., with the HAs Medical Director (MD), the MD reviewed picture of Patient 12s wound on the right lateral foot and stated that Patient 12s wound on the right lateral foot could be infected due to erythema (abnormal redness of the skin due to inflammation) and contained what appeared to be a small amount of purulent (thick milky or yellow discharge that comes out from the wound) or sloughing (dead skin shedding) . MD stated that Patient 12s wound from the right lateral foot could be from abrasion or pressure injury, or combination of both. MD stated that he was not notified since yesterday (11/6/2024) or even before regarding Patient 12s wound condition on right lateral foot. MD stated that he cannot remember if he got notified by any clinical staff regarding Patient 12s wound on right lateral foot. MD stated that Patient 12 is susceptible to develop pressure injury due to her being a bedbound, wheelchair bound and immobile. During a review of the HAs policy and procedure (P&P) titled, ";Initial and Comprehensive Assessment," updated 6/6/2024, the P&P indicated, ";The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services, and the patients need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions." The P&P further indicated that ";Updated Comprehensive Assessment 1. Demonstrates that all members of the IDG (Interdisciplinary Group) are actively involved in evaluating the patients care which including: 1. Identification of the care and needs of the patient based on assessment, 2. Ongoing assessment and monitoring of symptoms, 3. Provision of care planned interventions, 6. Recent accurate information about the patient/family to identify when changes to the POC are needed, and 7. The care and services needed." During a review of the HAs policy and procedure (P&P) titled ";Wound Care," the P&P indicated that "; all services necessary for the palliation and management of the terminal illness and related conditions, include the following: 1. Interventions to manage pain and symptoms, 4. Drugs and treatments necessary to meet the needs of the patient, assessments (nurse will visualize the wound and document on the integumentary portion of the Nursing Updated Comprehensive Assessment every 7 days, if a nurse visualizing the wound is a Licensed Vocational Nurse, they must report any changes to RN), documentations that include a complete wound assessment (location of wound, stage or classification, size: in centimeters (length x width x depth, odor), and care planning."

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (conditions that healthcare organizations must meet to begin and continue participating in the Medicare and Medicaid programs) for Interdisciplinary group, Care planning, and Coordination of services as follows: --- 1. The hospice agency (HA) failed to develop an individualized and patient-centered Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) to address patients skin abnormality on the right lateral foot and patients use of Eliquis (an anticoagulant [blood thinner] medication but can cause serious bleeding) for one of nineteen sampled patients (Patient 12). This deficient practice resulted in Patient 12, did not have a POC for the current health status for management of symptoms of terminal illness that is likely to cause delayed care, and undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of dying process. (Refer to L545). 2. The HA failed to provide necessary drugs for two of nineteen sampled patients (Patient 7 and Patient 12). This deficient practice had the potential to result in the patients comfort level impaired. (Refer to L549). 3. The HA failed to ensure that the care and services were communicated with the hospice team to ensure treatment and services were appropriately provided to one of fourteen sampled patients (Patient 12). For Patient 12, The Medical Director (MD) and the Patient Care Administrator (PCA) were not aware of Patient 12s untreated skin abnormality on right lateral foot. (Refer to L554). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulations for Interdisciplinary group, Care planning, and Coordination of services, to ensure provision of quality care and services to patients assessed to receive hospice services.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to develop an individualized and patient-centered Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) to address patients skin abnormality on the right lateral foot and patients use of Eliquis (an anticoagulant [blood thinner] medication but can cause serious bleeding) for one of nineteen sampled patients (Patient 12). This deficient practice resulted in Patient 12, did not have a POC for the current health status for management of symptoms of terminal illness that is likely to cause delayed care, and undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of dying process. --- During a review of Patient 12s ";Case Sheet," the Case Sheet indicated Patient 12 was admitted to the HA on 11/17/2023 with a terminal diagnosis of ";Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior)." During a review of Patient 12s ";Addendum Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) Review/Recert Note," dated 8/28/2024, indicated that Patient 12's nurse visit frequency of once a week, with a recertification period from 9/12/2024 to 11/11/2024. During a review of Patient 12s ";RN (Registered Nurse) Initial Comprehensive Assessment," dated 11/18/2023, the RN Initial Comprehensive Assessment indicated in the ";Wounds/Integumentary (Skin or bodys outer layer)" section was marked check for ";Assessed, no Integumentary Symptoms identified – NA (Not Applicable." During a joint home visit observation, and interview on 11/6/2024 at 12:25 p.m., with Registered Nurse 3 (RN 3) to Patient 12s residence, Patient 12 was observed lying in bed, awake and oriented to her name only. RN 3 stated he had seen Patient 12 yesterday. Patient 12 resides in a board and care (licensed residential home for long term care individuals) setting, and the House Manager (HM), who acted as her primary caregiver, was observing the visit. Both RN 3 and HM confirmed and stated that Patient 12 has no existing wounds. RN 3 conducted a skin assessment on Patient 12. Patient 12 had a band aid (a piece of sticking plaster with pad in the center, used to cover wound) covering Patient 12s middle area of right lateral foot. RN3 removed the band aid. Patient 12 had a skin abnormality that appeared as having a necrotic (dead) tissue, black in color in the center area, round, small amount of yellow discharge, yellow slough (dead skin shedding), redness/slight swelling to surrounding area and measured approximately less than two centimeters (cm) in width and length. RN 3 stated that he came to see Patient 12 yesterday (11/5/2024), RN 1 stated that he missed to conduct a thorough head to toe assessment with Patient 12. RN 3 stated that Patient 12s skin abnormality appeared to be a skin tear and could also be a stage 2 pressure injury (characterized as open wounds, skin breaks open, wears away, or forms an ulcer, which is usually tender and painful, the wound expands into deeper layers of the skin and can look like a scrape (abrasion), blister, or a shallow crater in the skin), RN 3 stated that the center area of the wound, when he palpated was hard, has black in color in the center area, round, has a small amount of yellow discharge, yellow slough (dead skin shedding), redness/slight swelling to surrounding area. RN 3 measured the wound with approximately less than two centimeters (cm) in width and length. Patient 12 retracted her right foot when RN 3 gently palpated the wound located at right lateral foot. RN 3 stated that it could be a pressure injury since Patient 12 is immobile and bed bound. RN 3 stated that he does not know since when Patient 12 has her wound from right lateral foot. RN 3 stated that it is important to conduct a skin assessment for patient, on each visit, to identify for any presence of wounds and to have it communicated to the physician for any wound treatment orders and care plans. RN 3 stated that he has no documentation of skin assessment particularly to Patient 12s wound on right lateral foot since he did not identify it. RN 3 stated that not identifying Patient 12s wound could result in infection and worsening condition if not treated. During an interview with HM at 11:55 a.m., HM stated that Patient 12 had scab on her right lateral foot for months. HM stated that she reported it to the visiting nurses and was told that they are going to send the supplies for the wound treatment. HM stated that she told to the visiting nurses twice, around September 2024 and October 2024. HM stated that Patient 12 is unable to reposition herself and is total dependent, HM stated that she repositioned her frequently every 2 hours as she is thin and is susceptible to develop pressure injury. HM stated that there was no current wound treatment done to Patient 12s wound on her right lateral foot and it looked worse than before HM confirmed and stated that RN 3 came yesterday (11/5/2024) and visited Patient 12 but did not gave him any instructions regarding wound treatment of Patient 12s wound on right lateral foot. During a review of Patient 12s clinical record ";Active Medications," with RN3, the Active Medication listed a medication which includes: - Eliquis 2.5 milligrams (mg, unit of weight) tablet, one tablet, by mouth, two times daily for the heart. RN 3 stated that he provided teachings to HM on signs and symptoms to watch for while Patient 12 is on Eliquis such as unusual bruising, black stools, nose bleeding or prolong bleeding. HM stated that she was unsure if the HA visiting nurses provided her teachings about the bleeding precautions. During an interview and concurrent record review of Patient 12s following clinical records on 11/7/2024, at 10:30 a.m., with the Patient Care Administrator (PCA) and National Patient Care Administrator (RN4): - Patient 12s clinical record titled ";Interdisciplinary (ID, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Plan of Care (POC)Revision/Physician Orders," dated 10/2/2024, the ID POC Revision/Physician Orders indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. - Patient 12s clinical record titled ";Plan of Care (POC) Review for Recertification," dated 8/28/2024, the POC Review for Recertification indicated on section ";Response to Care and Updates to Comprehensive Assessment" on area of ";Integumentary" was left blank with no documentation. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN4 stated that it was left bank since there was no problem or area of concern on Patient 12 s skin integrity. - Patient 12s clinical record titled ";Plan of Care (POC) Review," dated 8/14/2024, 8/28/2024 and 9/24/2024, the POC review indicated on section ";Response to Care and Updates to Comprehensive Assessment" on area of ";Integumentary" was left blank with no documentation for the dates of 8/14/2024 and 8/28/2024, and for the date of 9/24/2024, on area of ";Integumentary" with documentation of ";skin intact." RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN4 stated that section ";Integumentary" was left bank since there was no problem or area of concern on Patient 12 s skin integrity. - Patient 12s clinical record titled ";Focus Visit," dated 8/27/2024 and 8/29/2024, the Focus Visit indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN 4 stated that Focus Visit is completed by the visiting nurses. - Patient 12s clinical record titled ";Nursing-Updated Comprehensive Assessment," dated 9/5/2024, 9/15/2024, 9/24/2024, 10/2/2024, 10/16/2024 and 10/29/2024, the Nursing-Updated Comprehensive Assessment indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN 4 stated that if Patient 12s wound on right lateral foot is located on the pressure spot then it could be a pressure injury, RN 4 stated it looks like unstageable and the lateral side of the right foot can be a pressure spot, RN 4 stated that it appeared like sloughing and not a purulent discharge but the redness on the surrounding area and discoloration are present and could be a skin breakdown on surface of the wound.. RN 4 stated that visiting nurse should contact the physician and obtain wound care orders. RN 4 stated that the visiting nurse that identified the patients wound should conduct a complete assessment of wound that includes the measurement, description, location, and characteristics that would reflect to patients clinical records. RN 4 stated that after patients wound was assessed, it must have care plan, obtain a treatment order from the physician, and discuss it with the ID team. RN 4 stated that potential outcome, if patients wound not treated, will result in further skin breakdown, infection, sepsis, that could lead to hospitalization. Both PCA and RN 4 stated that HA did not have any evidence of skin assessments, wound treatments and plan of care in relation to Patient 12s wound on right lateral foot and bleeding precautions while on anti-coagulant medications. RN 4 stated that expectation with the visiting nurse is to provide teaching of patients medications with symptoms, adverse effects and precautions, and it has to be documented. A review of the HAs policy and procedure (P&P), titled ";VS Pharmacy Process," undated, the P & P indicated in the "Patient and Family Pharmacy Education," (7.) Education interventions on the POC should be updated for new medications and continued medication monitoring (safety, efficacy, ability to administer, medication reconciliation, etc.).

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide drugs and treatment necessary to meet their needs for two of nineteen sampled patients (Patient 7 and Patient 12). This deficient practice had the potential to result in the patients comfort level impaired. --- a. A review of Patient 7s Case Sheet indicated Patient 7 was admitted on 10/31/2024 with a primary diagnosis of Alzheimers disease (a type of brain disorder that causes problems with memory, thinking and behavior), unspecified. A review of Patient 7s Interdisciplinary Care Plan (a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 10/31/2024, indicated the interventions for Patient 7 included medications (drug interactions/treatment indications, use, and side effects). During a joint visit with Registered Nurse 2 (RN 2) on 11/6/2024 at 1:10 p.m., observed Patient 7 lying in bed with both eyes closed. Patient 7 responded by opening her eyes when RN 2 called her name. Patient 7 resided in Assisted Living Facility 1 (ALF 1). During the joint visit, a medication review was conducted with RN 2 and Licensed Vocational Nurse 2 (LVN 2). LVN 2 is a nursing staff employed by ALF 1 and was assigned to Patient 7. A review of Patient 7s Chart Medication List/Signed Physician Orders, printed on 11/5/2024, indicated that Zofran (a medication that prevents nausea and vomiting caused by chemotherapy, radiation, or surgery) 4 Mg (a measurement unit) tablet was ordered for Patient 7. The instruction for Zofran 4 mg was as follows: Take one tablet (4 Mg) by mouth every four hours as needed for nausea and/or vomiting. Upon medication review on, LVN 2 stated that Patient 7 did not have an order for Zofran 4 Mg, therefore Zofran 4 mg was not available. During a concurrent record review and interview with RN 2 on 11/6/2024 at 1:50 p.m., RN 2 confirmed that Zofran 4 Mg was not listed on Patient 7s Physicians Orders maintained by ALF 1. RN 2 stated that Zofran 4 Mg was ordered by the HAs physician as part of the comfort kit, but somehow it did not get transcribed to the ALF 1s Physicians Orders. During the interview, RN 2 stated that even though the instruction for Zofran 4 Mg was to be taken as needed for nausea and/or vomiting, it was important to ensure medication availability, so when the patient needed it, she would be able to take it. During a concurrent record review and interview with the Patient Care administrator (PCA) on 11/7/2024 at 1:20 p.m., the PCA reviewed Patient 7s Chart Medication List/Signed Physician Orders and Physicians Orders maintained by ALF 1. The PCA stated all orders in the Chart Medication List/Signed Physician Orders were supposed to be transcribed to the Physicians Orders. The PCA stated for patients residing in a facility, the HAs staff needed to maintain communication with the facilitys staff to ensure they were on the same page. A review of the HAs policy and procedure, titled ";VS Pharmacy Process," undated, indicated the HAs nurse was responsible for ensuring availability of medications by monitoring medications amount every visit, and order refills to ensure adequate supply in place until next visit. b. During a review of Patient 12s ";Case Sheet," the Case Sheet indicated Patient 12 was admitted to the HA on 11/17/2023 with a terminal diagnosis of ";Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior)." During a review of Patient 12s ";Addendum Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) Review/Recert Note," dated 8/28/2024, the Addendum POC Review/Recert Note indicated that Patient 12's nurse visit frequency of once a week, with a recertification period from 9/12/2024 to 11/11/2024. During a joint home visit observation, and interview on 11/6/2024, at 12:25 p.m., with Registered Nurse 3 (RN 3) to Patient 12s residence, Patient 12 was observed lying in bed, awake and oriented to her name only. RN 3 stated he had seen Patient 12 yesterday. Patient 12 resides in a board and care (licensed residential home for long term care individuals) setting, and the House Manager (HM), who acted as her primary caregiver, was observing the visit. During Patient 12s medication review with RN3 and comparison with the medication profile, it indicated that Patient 12 has a current order for Hyoscyamine 0.125 mg tablet Sublingual (SL, under the tongue) – take 1 tablet by mouth under the tongue every 4 hours as needed for excess secretions. NTE 6 tablets/24 hours, with an expiration date of 5/16/2024. Both the RN 3 and HM confirmed and stated that Hyoscyamine medication with a current date is not available for Patient 12. RN 3 and HM stated that they were not able to locate Patient 12s unexpired Hyoscyamine medication. HM stated that she is not aware that Patient 12 has no Hyoscyamine medication with a current date. During an interview with RN 3 at 1:00 p.m., RN 3 confirmed that Ibuprofen, Acetaminophen, Norco and Hyoscyamine medications had an expired date. RN 3 stated he is not aware that there were some expired medications of patient 12s medications. RN 3 stated medication reconciliation is done on each nurse visit and if there are any changes, missing or expired medications, HM should notify the agency. RN 3 stated he conducts medication reconciliation on each visit but missed Patient 12s missing and expired medications. RN 3 stated that it is important for a patient to not taking expired medications since it could be contraindicated, not beneficial to patient due to decreased efficacy and affects patients safety. HM stated she is not aware about the expiration date of the pain medications since Patient 12 has the same unexpired medications on stock and will use it. RN 3 stated that it was important to ensure that medication is on hand, so when the patient needed it, it would be readily available. During an interview on 11/7/2024, at 10:48 a.m., with the National Patient Care Administrator (RN 4), RN 4 stated that visiting nurses should conduct medication reconciliation for patients on each visit to determine and monitor expired or discontinued medications to prevent possible medication errors and to update the patients active medication list. RN 4 stated that administering expired medications to patient would not be beneficial and will result to decrease therapeutic effect and ineffective intervention. RN 4 stated that it was important to ensure that medications are not missing, so when the patient needed it, it would be readily available. b. During a review of Patient 12s ";Case Sheet," the Case Sheet indicated Patient 12 was admitted to the HA on 11/17/2023 with a terminal diagnosis of ";Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior)." During a review of Patient 12s ";Addendum Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) Review/Recert Note," dated 8/28/2024, the Addendum POC Review/Recert Note indicated that Patient 12's nurse visit frequency of once a week, with a recertification period from 9/12/2024 to 11/11/2024. During a joint home visit observation, and interview on 11/6/2024, at 12:25 p.m., with Registered Nurse 3 (RN 3) to Patient 12s residence, Patient 12 was observed lying in bed, awake and oriented to her name only. RN 3 stated he had seen Patient 12 yesterday. Patient 12 resides in a board and care (licensed residential home for long term care individuals) setting, and the House Manager (HM), who acted as her primary caregiver, was observing the visit. During Patient 12s medication review with RN3 and comparison with the medication profile, it indicated that Patient 12 has a current order for Hyoscyamine 0.125 mg tablet Sublingual (SL, under the tongue) – take 1 tablet by mouth under the tongue every 4 hours as needed for excess secretions. NTE 6 tablets/24 hours, with an expiration date of 5/16/2024. Both the RN 3 and HM confirmed and stated that Hyoscyamine medication with a current date is not available for Patient 12. RN 3 and HM stated that they were not able to locate Patient 12s unexpired Hyoscyamine medication. HM stated that she is not aware that Patient 12 has no Hyoscyamine medication with a current date. During an interview with RN 3 at 1 p.m., RN 3 confirmed that Ibuprofen, Acetaminophen, Norco and Hyoscyamine medications had an expired date. RN 3 stated he is not aware that there were some expired medications of patient 12s medications. RN 3 stated medication reconciliation is done on each nurse visit and if there are any changes, missing or expired medications, HM should notify the agency. RN 3 stated he conducts medication reconciliation on each visit but missed Patient 12s missing and expired medications. RN 3 stated that it is important for a patient to not taking expired medications since it could be contraindicated, not beneficial to patient due to decreased efficacy and affects patients safety. HM stated she is not aware about the expiration date of the pain medications since Patient 12 has the same unexpired medications on stock and will use it. RN 3 stated that it was important to ensure that medication is on hand, so when the patient needed it, it would be readily available. During an interview on 11/7/2024, at 10:48 a.m., with the National Patient Care Administrator (RN 4), RN 4 stated that visiting nurses should conduct medication reconciliation for patients on each visit to determine and monitor expired or discontinued medications to prevent possible medication errors and to update the patients active medication list. RN 4 stated that administering expired medications to patient would not be beneficial and will result to decrease therapeutic effect and ineffective intervention. RN 4 stated that it was important to ensure that medications are not missing, so when the patient needed it, it would be readily available. a. A review of Patient 7s Case Sheet indicated Patient 7 was admitted on 10/31/2024 with a primary diagnosis of Alzheimers disease (a type of brain disorder that causes problems with memory, thinking and behavior), unspecified. A review of Patient 7s Interdisciplinary Care Plan (a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 10/31/2024, indicated the interventions for Patient 7 included medications (drug interactions/treatment indications, use, and side effects). During a joint visit with Registered Nurse 2 (RN 2) on 11/6/2024 at 1:10 p.m., observed Patient 7 lying in bed with both eyes closed. Patient 7 responded by opening her eyes when RN 2 called her name. Patient 7 resided in Assisted Living Facility 1 (ALF 1). During the joint visit, a medication review was conducted with RN 2 and Licensed Vocational Nurse 2 (LVN 2). LVN 2 is a nursing staff employed by ALF 1 and was assigned to Patient 7. A review of Patient 7s Chart Medication List/Signed Physician Orders, printed on 11/5/2024, indicated that Zofran (a medication that prevents nausea and vomiting caused by chemotherapy, radiation, or surgery) 4 Mg (a measurement unit) tablet was ordered for Patient 7. The instruction for Zofran 4 mg was as follows: Take one tablet (4 Mg) by mouth every four hours as needed for nausea and/or vomiting. Upon medication review on, LVN 2 stated that Patient 7 did not have an order for Zofran 4 Mg, therefore Zofran 4 mg was not available. During a concurrent record review and interview with RN 2 on 11/6/2024 at 1:50 p.m., RN 2 confirmed that Zofran 4 Mg was not listed on Patient 7s Physicians Orders maintained by ALF 1. RN 2 stated that Zofran 4 Mg was ordered by the HAs physician as part of the comfort kit, but somehow it did not get transcribed to the ALF 1s Physicians Orders. During the interview, RN 2 stated that even though the instruction for Zofran 4 Mg was to be taken as needed for nausea and/or vomiting, it was important to ensure medication availability, so when the patient needed it, she would be able to take it. During a concurrent record review and interview with the Patient Care administrator (PCA) on 11/7/2024 at 1:20 p.m., the PCA reviewed Patient 7s Chart Medication List/Signed Physician Orders and Physicians Orders maintained by ALF 1. The PCA stated all orders in the Chart Medication List/Signed Physician Orders were supposed to be transcribed to the Physicians Orders. The PCA stated for patients residing in a facility, the HAs staff needed to maintain communication with the facilitys staff to ensure they were on the same page. A review of the HAs policy and procedure, titled ";VS Pharmacy Process," undated, indicated the HAs nurse was responsible for ensuring availability of medications by monitoring medications amount every visit, and order refills to ensure adequate supply in place until next visit.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the care and services were communicated with the hospice team to ensure treatment and services were appropriately provided to one of fourteen sampled patients (Patient 12). For Patient 12, the Medical Director (MD) and the Patient Care Administrator (PCA) were not aware of Patient 12s untreated skin abnormality on right lateral foot. This deficient practice resulted in Patient 12 not receiving appropriate care, treatment and services to meet the care goals needs. --- During a review of Patient 12s ";Case Sheet," the Case Sheet indicated Patient 12 was admitted to the HA on 11/17/2023 with a terminal diagnosis of ";Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior)." During a review of Patient 12s ";Addendum Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) Review/Recert Note," dated 8/28/2024, the Addendum POC Review/Recert Note indicated that Patient 12's nurse visit frequency of once a week, with a recertification period from 9/12/2024 to 11/11/2024. During a review of Patient 12s ";RN (Registered Nurse) Initial Comprehensive Assessment," dated 11/18/2023, the RN Initial Comprehensive Assessment indicated in the ";Wounds/Integumentary (Skin or bodys outer layer)" section was marked check for ";Assessed, no Integumentary Symptoms identified – NA (Not Applicable." During a joint home visit observation, and interview on 11/6/2024 at 12:25 p.m., with Registered Nurse 3 (RN 3) to Patient 12s residence, Patient 12 was observed lying in bed, awake and oriented to her name only. RN 3 stated he had seen Patient 12 yesterday. Patient 12 resides in a board and care (licensed residential home for long term care individuals) setting, and the House Manager (HM), who acted as her primary caregiver, was observing the visit. Both RN 3 and HM confirmed and stated that Patient 12 has no existing wounds. RN 3 conducted a skin assessment on Patient 12. Patient 12 had a band aid (a piece of sticking plaster with pad in the center, used to cover wound) covering Patient 12s middle area of right lateral foot. RN3 removed the band aid. Patient 12 had a skin abnormality that appeared as having a necrotic (dead) tissue, black in color in the center area, round, small amount of yellow discharge, yellow slough (dead skin shedding), redness/slight swelling to surrounding area and measured approximately less than two centimeters (cm) in width and length. RN 3 stated that he came to see Patient 12 yesterday (11/5/2024), RN 1 stated that he missed to conduct a thorough head to toe assessment with Patient 12. RN 3 stated that Patient 12s skin abnormality appeared to be a skin tear and could also be a stage 2 pressure injury (characterized as open wounds, skin breaks open, wears away, or forms an ulcer, which is usually tender and painful, the wound expands into deeper layers of the skin and can look like a scrape (abrasion), blister, or a shallow crater in the skin), RN 3 stated that the center area of the wound, when he palpated was hard, has black in color in the center area, round, has a small amount of yellow discharge, yellow slough (dead skin shedding), redness/slight swelling to surrounding area. RN 3 measured the wound with approximately less than two centimeters (cm) in width and length. Patient 12 retracted her right foot when RN 3 gently palpated the wound located at right lateral foot. RN 3 stated that it could be a pressure injury since Patient 12 is immobile and bed bound. RN 3 stated that he does not know since when Patient 12 has her wound from right lateral foot. RN 3 stated that it is important to conduct a skin assessment for patient, on each visit, to identify for any presence of wounds and to have it communicated to the physician for any wound treatment orders and care plans. RN 3 stated that he has no documentation of skin assessment particularly to Patient 12s wound on right lateral foot since he did not identify it. RN 3 stated that not identifying Patient 12s wound could result in infection and worsening condition if not treated. During an interview with HM at 11:55 a.m., HM stated that Patient 12 had scab on her right lateral foot for months. HM stated that she reported it to the visiting nurses and was told that they are going to send the supplies for the wound treatment. HM stated that she told to the visiting nurses twice, around September 2024 and October 2024. HM stated that Patient 12 was unable to reposition herself and was total dependent, HM stated that she repositioned her frequently every 2 hours as she was thin and was susceptible to develop pressure injury. HM stated that there was no current wound treatment done to Patient 12s wound on her right lateral foot and it looked worse than before HM confirmed and stated that RN 3 came yesterday (11/5/2024) and visited Patient 12 but did not gave him any instructions regarding wound treatment of Patient 12s wound on right lateral foot. During an interview and concurrent record review of Patient 12s following clinical records on 11/7/2024, at 10:30 a.m., with the Patient Care Administrator (PCA) and National Patient Care Administrator (RN4): - Patient 12s clinical record titled ";Interdisciplinary (ID, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Plan of Care (POC)Revision/Physician Orders," dated 10/2/2024, the ID POC Revision/Physician Orders indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. - Patient 12s clinical record titled ";Plan of Care (POC) Review for Recertification," dated 8/28/2024, the POC Review for Recertification indicated on section ";Response to Care and Updates to Comprehensive Assessment" on area of ";Integumentary" was left blank with no documentation. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN4 stated that it was left bank since there was no problem or area of concern on Patient 12 s skin integrity. - Patient 12s clinical record titled ";Plan of Care (POC) Review," dated 8/14/2024, 8/28/2024 and 9/24/2024, the POC review indicated on section ";Response to Care and Updates to Comprehensive Assessment" on area of ";Integumentary" was left blank with no documentation for the dates of 8/14/2024 and 8/28/2024, and for the date of 9/24/2024, on area of ";Integumentary" with documentation of ";skin intact." RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN4 stated that section ";Integumentary" was left bank since there was no problem or area of concern on Patient 12 s skin integrity. - Patient 12s clinical record titled ";Focus Visit," dated 8/27/2024 and 8/29/2024, the Focus Visit indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN 4 stated that Focus Visit is completed by the visiting nurses. - Patient 12s clinical record titled ";Nursing-Updated Comprehensive Assessment," dated 9/5/2024, 9/15/2024, 9/24/2024, 10/2/2024, 10/16/2024 and 10/29/2024, the Nursing-Updated Comprehensive Assessment indicated no assessment, identification, intervention, and treatment orders for Patient 12s wound on her right lateral foot. RN4 and PCA both confirmed and stated that there was no clinical documentation particularly to Patient 12s wound on right lateral foot. RN 4 stated that if Patient 12s wound on right lateral foot was located on the pressure spot then it could be a pressure injury, RN 4 stated it looked like unstageable and the lateral side of the right foot can be a pressure spot, RN 4 stated that it appeared like sloughing and not a purulent discharge but the redness on the surrounding area and discoloration are present and could be a skin breakdown on surface of the wound.. RN 4 stated that visiting nurse should contact the physician and obtain wound care orders. RN 4 stated that the visiting nurse that identified the patients wound should conduct a complete assessment of wound that included the measurement, description, location, and characteristics that would reflect to patients clinical records. RN 4 stated that after patients wound was assessed, it must have care plan, obtain a treatment order from the physician, and discuss it with the ID team. RN 4 stated that potential outcome, if patients wound not treated, will result in further skin breakdown, infection, sepsis, that could lead to hospitalization. Both PCA and RN 4 stated that HA did not have any evidence of skin assessments, wound treatments and plan of care in relation to Patient 12s wound on right lateral foot. During an interview on 11/7/2024, at 1:16 p.m., with the HAs Medical Director (MD), the MD reviewed picture of Patient 12s wound on the right lateral foot and stated that Patient 12s wound on the right lateral foot could be infected due to erythema (abnormal redness of the skin due to inflammation) and contained what appeared to be a small amount of purulent (thick milky or yellow discharge that comes out from the wound) or sloughing (dead skin shedding) . MD stated that Patient 12s wound from the right lateral foot could be from abrasion or pressure injury, or combination of both. MD stated that he was not notified since yesterday (11/6/2024) or even before regarding Patient 12s wound condition on right lateral foot. MD stated that he cannot remember if he got notified by any clinical staff regarding Patient 12s wound on right lateral foot. MD stated that Patient 12 is susceptible to develop pressure injury due to her being a bedbound, wheelchair bound and immobile. During a review of the HAs policy and procedure (P&P) titled, ";Coordination of Care," undated, the P&P indicated, ";The responsibilities of the RN Coordinator for the agency include: 1. To alert the facility nurse and the hospice team regarding changes in the patients condition and document those changes as well as to whom it was reported in the note."

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure that the grievance was investigated, resolved and documented accordingly when the agency received a report/service comment for Patient 1 who did not have pain medication readily available at the time of admission to the skilled nursing facility (SNF-a place where people can temporarily live while they receive medical treatments and rehabilitation after an illness or injury ). This deficient practice had the potential to result in the lack of coordination of the patient's clinical information and lack of continuity of care of the hospice services provided by the HA. --- A complaint validation survey (a type of survey conducted by the Centers for Medicare & Medicaid Services (CMS) to investigate allegations of noncompliance with Medicare to assess the ability of an accredited provider or supplier to comply with Medicare conditions) was conducted at this agency location on 11/5/2024 to 11/8/2024. During a review of the HAs complaint log on 11/5/2024 at 11:10 a.m., indicated that the agency had a total of 52 complaints starting from 2/2/2024 to 10/23/2024. A review on Patient 1s document titled "; Case Sheet" showed that Patient 1 was admitted to the hospice agency on 2/2/2024 with a diagnosis of sepsis (a life-threatening medical emergency that occurs when the body's immune system overreacts to an infection or injury) and conversion disorder with seizures (a mental health condition where a person experiences seizure-like episodes, often appearing similar to epileptic seizures, but originating from psychological stress rather than neurological abnormalities). A review of Patient 1s document titled ";History and Physical" authored by the hospice agencys medical director (MD) and signed on 2/12/2024, MD wrote that Patient 1s history of present illness indicated the patient was referred from acute hospital with a complicated history that began in July 2023. She presented with altered mental status at the acute hospital and subsequently had 3 craniotomies (in a surgical procedure that involves removing a portion of the skull to access the brain) including a brain biopsy (study of a tissue of the brain) that revealed herpes simplex virus 1(a common virus that causes blisters in a part of the body). She sustained an intracerebral hemorrhage (bleeding from the brain) followed by complications of hydrocephalus (enlargement of the brain due to increase in fluid) requiring the placement of external ventricular drain (EVD, a medical device that's used to drain excess fluid from the brain's ventricles). Subsequently, she developed pseudo meningocele ( a collection of fluid in the brain) and her CSF( cerebrospinal fluid- the fluid that flows in the spinal cord) cultures grew out Candida parapsilosis (a type of fungus that lives in the body) and was treated with intravenous (IV- thru the vein) amphotericin and flucytosine ( types of antifungal medication) She developed seizure disorder (a sudden burst of electrical activity in the brain. It can cause changes in behavior, involuntary movements and feelings) right-sided hemiparesis (right side of the body that cannot move or function), and aphasia (a language disorder that makes it hard to communicate) and had a rocky course. Her pain was managed with IV Dilaudid (a kind of pain medication) with significant functional and cognitive decline, requiring aggressive comfort and palliative care measures under the direction of this hospice under a high level of care (GIP- general inpatient car a short-term level of hospice care for patients who need acute symptom control or pain management that can't be managed in other settings). During a review of the agencys document titled ";Service Comment Form" on 11/5/2024 at 11:10 a.m., indicated that on 2/2/2024, Patient 1s complaint was listed and initiated by the former Patient Care Administrator indicating that an ";RN arrived at facility to complete initial comprehensive assessment (ICA) and received patient in pain. No pain medication was available upon SN (skilled nurse) arrival. It took eight hours for patient to receive first dosage of pain medication after arriving at the skilled nursing facility (SNF)." During a review of the agencys document titled ";Service Comment Form" on 11/8/2024 at 11:10 a.m., indicated that ";Actions/Interventions/Follow-up to Address Complaints and to Prevent Recurrence" indicated 2/8/2024, Director of Admissions (DA) discussed with new admission nurse (AN) and discovered lack of her not understanding the process of ordering medications for facility patients. During a review of the agencys document titled ";Service Comment Form" on 11/8/2024 at 11:10 a.m., indicated that ";Actions/Interventions/Follow-up to Address Complaint and to Prevent Recurrence" indicated that on 2/9/2024 indicated that the Director of Admissions to educate the staff on the importance of making sure when discharging a patient to a skilled nursing facility, assisted living facility (ALF), Board and Care (B&C), home all comfort measures are in place (order from a local pharmacy). Collaborate effectively with the team Manager/Patient Care Administrator to assure staff has been assigned at a SNF medications can not be ordered until patient arrives. There was no written documentation on how the agency conducted their investigation of the complaint and what the agency did for the facility involved when the facility was unable to provide medications for Patient 1. There was no documentation on what the agency did to resolve the admissions nurse that had the lack of understanding about the process of ordering medications. During a review of the agencys document titled ";Service Comment Form" on 11/8/2024 at 11:10 a.m., indicated that on ";Outcome/Resolution" indicated that the complaint was resolved on 2/8/2024 and final review by the current General Manager/Administrator dated 6/18/2024. During a joint interview and concurrent record review with the current General Manager/Administrator (GM) and Patient Care Administrator (PCA) on 11/8/2024 at 11:30 a.m., GM stated she started working as the GM for this agency eight months ago. GM stated that she just closed the complaint. GM stated that the clinical oversight being provided by the National Patient Care Administrator/Registered Nurse 4 (RN 4). PCA stated that she started three months ago and was still under training by the National Patient Care Administrator (RN4). PCA stated that she was only overseeing telecare (phone reports after hours) results and complaints that needed to be followed through. PCA stated that she was doing financial and the day-to-day reports. PCA also stated she conducts daily stand-up meeting. GM stated that the complaint was received by making a service comment and the one of the team will investigate and then it will go to the national or regional level. During an interview on 11/8/2024 at 150 p.m., with the national Patient Care Administrator/Registered Nurse 4 (RN 4) stated that there was another National PCA providing clinical oversight for the agency when the former PCA and GM left. RN 4 stated that in reference to the new PCA this time even if the new PCA was still training under my supervision, the new PCA could still provide clinical oversight with the help of the new team managers resolving issues that arises in the agency. RN 4 stated that if the issue needs to be referred to the national level or raise up to the regional level including the Chief Nursing Officer for any inquiries that needs to be resolved. RN 4 stated that she was not present at the agencys location but would come to the agency when needed. During a review of the hospice agencys document titled ";VS Admission Process" page 46 indicated i. The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any). ii. In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: (1) Diagnosis of the terminal condition of the patient.(2) Other health conditions, whether related or unrelated to the terminal condition.(3) Current clinically relevant information supporting all diagnoses. Page 44: iv) Same Day Discharge: i. Evaluation of a patient in a facility where the hospice care will not be provided, and the patient will arrive at the site of care location the same dayii. Pre-Admission Evaluation is completed at pre admit location iii. Admission orders completed when patient is at pre admit location i. Include 'Orders and admission effective upon arrival to site of care location'iv. Initial RN Comprehensive Assessment should be completed at the site of care location so an environmental assessment can be completed v. Preparation for discharge home i. Work with facility Discharge Plannerii. Ambulance transportation to the patients' home prior to the completion of the Initial Comprehensive Assessment and Plan of Care is not usually covered on the hospice plan of care i. See VS. Ambulance Transportation for additional information iii. Ensure that the Immediately needed HME, Supplies and Medications not currently at site of care location are in place by the time the patient arrives at home i. The patient/caregiver may pick up medications in route to or after arrival to site of care location vi. Communication i. Report to AC i. See VS Admission Reporting for reporting details ii. The AC updates Vx status qualifier to "Transfer to Patient Care· ii. Ensure patient and family are aware they are not on service until arrival at the site of care location and they need to notify the local VITAS office as soon as they arrive i. If the patient/family has not contacted VITAS by the estimated time of arrival, Telecare or the VITAS program will call to inquire ii. Ensure the patient and family are aware a staff member from the team will visit today at the site of care location to complete the Initial Comprehensive Assessment (VITAS does not have a "tuck-in" visit type)i. This visit should be from a RNii. In the rare instance where this visit is declined, the refusal should be documented per Vitas Standards iii. Refer to VS Initial and Comprehensive Assessments for additional information iv. An admission may technically run over to the next day when a patient arrives at the site of care location close to midnight. iii. Report to team i. Include anticipated time of patient arrival in your report to the team. ii. Ensure a copy of the AO is sent with the patient and they are in Https://Docs.Vitas.Com for access by the team. • Coordinate all required orders for home care (i.e. OME, prescriptions, continuous care, etc.) with the team, AC, pharmacy, as appropriate. A review of the hospice agency's document titled " VS LTC Coordination of Care" page 169 indicated Coordination of services. The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, toi) Ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided.ii) Ensure that the care and services are provided in accordance with the plan of care.iii) Ensure that the care and services provided are based on all assessments of the patient and family needs.iv) Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.v) Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. page 175 2. Documentation1. The hospice and nursing facility surveyors will be checking to see if the following documents are available in the nursing home medical record1. Hospice Election form2. Advance Directives, if any3. Physician Certification and Recertification(s)4. Hospice contact information1. Place a Resident Contact Form in each facility chart1. Preferably place it on the front of the chart2. Identifies that the patient is on VIT AS3. Includes program specific contact information and how to contact Vitas 24/7 medication continues to be of benefit. A review of the agency's document titled "Job Description: General Manager" revised 2/2/2018 indicated This position exists to (1) oversee the local functioning of corporate operational systems; (2) develop and expand the revenue performance and business potential of the hospice; (3) responsible for the patient and family services program at the hospice; (4) to represent the company in the community. Responsibilities: A. Overseeing the Local Functioning of Corporate Operational Systems1. By implementing the company's systems, policies, and standards, the general manager assures that the hospice meets and exceeds all applicable regulatory requirements of agencies and assumes responsibility for the readiness of the hospice to meet all inspections, surveys, and review - including state licensure, federal certifications, and accreditations. 2. The general manager assures policies in the following manner: a. Maintains a working knowledge df and ensures the program management adheres to the Medicare Conditions of Participation.b. Supervising the compliance of all administrative functions and policies with applicable regulatory agencies - i.e., keeping personnel records up to date for Medicare surveys.c. Maintaining a working knowledge of all applicable federal and state regulations, statutes and VIT AS policies and procedures, including staying up to date on the changing healthcare environment and its impact on the hospice business.d. Coordinating with the appropriate corporate staff, medical director, PCA and/or team manager and admissions manager all activity necessary to assure readiness in the hospice for an on-site survey by applicable regulatory agencies.e. Coordinating with VPO, Regional Medical Director, NPCA, and RDMD and other corporate resources when necessary for guidance and support. A review of the agency's document titled " Job Description: Patient care Administrator" revised last 2/3/2022 indicated that a The Patient Care Administrator is a member of the Senior Management Leadership Team, and is responsible for maintaining overall clinical, fiscal, and financial integrity of patient care, while meeting internal and external customer needs. The Patient Care Administrator functions as the hospice program's supervising nurse. Job Responsibilities: 1. Patient Care Services• Assures that the policies, mission, philosophy and values of VIT AS are upheld in the delivery of patient care services.• Ensures that Hospice care is provided to the ultimate satisfaction of patients and their families.• Actively collaborates with Team Manager(s), Medical Director, and Admissions Department on clinically complex cases.• Works in collaboration with the Admissions Manager to ensure patient care resources are available for pending admissions.• Acts as a clinical resource in collaboration with the Medical Director.• Works in collaboration with the Medical Director and the Senior Management team regarding the process for all alive discharges in the program.• Oversee the program clinical operations staff adherence to policies, procedures, and standards. 2. Staff Supervision and Management• Assures that nursing services are available 24 hours a clay, 7 days a week to meet patient and caregiver needs.• Ensures licensed practical nurses and home attendants work under the direct supervision of a registered nurse.• Responsible for the oversight of hiring, training, supervising, coaching and mentoring of clinical operations staff• Interviews, hires, supervises, mentors and evaluates the performance of direct reports.• Oversee and participate as needed in counseling and tennination of clinical operations-staff.• Facilitates and participates in regular meetings with direct clinical operations leadership team.• Recurring individual mentoring meetings with direct reports onsite and in the field. 3. Quality Improvement/Regulatory Compliance• Collaborates with senior management, direct reports, performance improvement specialist, and other programs in identification of trends, and potential Performance Improvement Plans as well as participating in and providing overall direction for clinical Performance Improvement Plans.• Ensures all program-required audits are completed.• Collaborates with Medical Records Claims Review Team for external audits and records requests, to ensure timely and accurate submission of requested documentation.• Proactively prepares for potential internal and external surveys, assuring compliance with policies, procedures, standards, Federal, State and local regulations are followed.• Actively participates in internal and external committees relevant to the program.• Participate in quality improvement reviews and evaluations of services provided.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the hospice did not ensure that volunteer services were offered. Clinical Record 12: The patient elected hospice care on 02/20/2024. In the initial comprehensive assessment section for the volunteer, the "further evaluation requested" was not addressed. The "not needed/declined" checkbox for the volunteer services was left blank. There was no evidence that volunteer services were offered at admission. Clinical Record 14: The patient elected hospice care on 03/27/2023. In the initial comprehensive assessment section for the volunteer, the "further evaluation requested" was not addressed. The "not needed/declined" checkbox for the volunteer services was left blank. There was no evidence that volunteer services were offered at admission. Clinical Record 18: The patient elected hospice care on 02/15/2024. In the initial comprehensive assessment section for the volunteer, the "further evaluation requested" was not addressed. The "not needed/declined" checkbox for the volunteer services was left blank. There was no evidence that volunteer services were offered at admission. Clinical Record 19: The patient elected hospice care on 02/16/2023. In the initial comprehensive assessment section for the volunteer, the "further evaluation requested" was not addressed. The "not needed/declined" checkbox for the volunteer services was left blank. There was no evidence that volunteer services were offered at admission. During an interview and a joint review of the records on 04/11/2024, the Patient Care Administrator/Registered Nurse (RN) confirmed the finding. In 5 of 19 (26%) clinical records reviewed revealed there was no evidence that a volunteer was offered and/or the patient declined volunteer services.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. Agency policy #5:20, "Interdisciplinary Team Policies Clinical Record" (revised May 2004), stated in the relevant part, "Every entry will be validated by the person making the entry with name, title, and date." In 3 of 19 (16%) clinical records reviewed, the hospice did not ensure that all entries were legible, appropriately authenticated, and dated in accordance with hospice policy. Clinical Record 1: The patient elected hospice care on 11/03/2023. The date "12/28/202" documented at the top of the form titled "Initial General Plan of Care" did not include complete documentation of the year. The signature of the Registered Nurse (RN) on the "Initial General Plan of Care" included documentation of the date "12//2023." The date documented did not include the day of the month. Clinical Record 2: The patient elected hospice care on 03/02/2024. The date of the "psychosocial/spiritual comprehensive assessment (page 1 of 5) visit was "scratched" out, making it difficult to ascertain the date. Clinical Record 3: The patient elected hospice care on 10/19/2023. A review of the initial comprehensive assessment dated 10/19/2023 revealed the patient identification (ID) number and blood pressure (BP) were "scratched" out (p 1 of 10). During an interview and a joint record review on 04/11/2024, the Patient Care Administrator/RN confirmed the finding, stating they must re-educate the staff regarding error notations. In 4 of 19 (21%) clinical records reviewed revealed the hospice did not ensure that patient entries were legible and appropriately dated.

Based on observation, interview, and record review, the hospice Agency (HA) failed to meet the Condition of Participation for Initial and Comprehensive Assessment of Patients as follows: 1. The HA failed to conduct comprehensive assessments (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) of wounds that would reflect wounds status for one of 13 sampled patients, (Patient 7). Refer to L 521. 2. The HA failed to review the patient's medications with the medication profile for 1 of 13 sampled patients, (Patient 7). Refer to L 530. The cumulative effect of these systemic practices resulted in the Hospice agency's inability to ensure the provision of quality health.

d. A review of Patient 5's clinical record indicated, Patient 5 was 46 years female who started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 could drive. During an interview with Patient 5 on 9/7/2022, at 10:30 a.m., it was observed Patient 5 was alert, oriented, and was able to communicate well. Patient 5 stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehensive Nursing Assessment" dated 12/28/2021 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane, and had steady gait. Patient 5 had mild dyspnea with mild exertion, and requires oxygen at 2 liters per minute as needed. Patient 5 was observed using chest accessory muscle after activity or walking, and the oxygen saturation at room air was 85 percent. The patient took two puffs of her Albuterol HFA 90 mcg oral inhalation, and after few minutes of rest, the patient's oxygen saturation had improved to 90 percent. Patient 5 had dull ache pain on both lower legs at a level of 4/10 on a pain scale. Diclofenac Sodium 1 % topical 2-4 times per day for pain management, and the pain was managed well ( reassessed pain prior to end the visit and the pain level was 2/10). A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 12/28/2021, indicated the section 1 and 2 should be met. It indicated Patient 5 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity, had Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. A review of Patient 5's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 12/28/2021 to 3/27/2022, indicated, Patient 5's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". e. A review of Patient 6's clinical record indicated, Patient 6 was 64 years old male who started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehensive Nursing Assessment" dated 7/14/2021 indicated Patient 6 was alert and oriented, used a cane for ambulation, and bowel and urinary status was continent. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/14/2021, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Increased visits to Emergency Room *Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, or had Increased visits to Emergency Room, and the oxygen saturation rate was less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 6's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". f. A review of Patient 7's clinical record indicated, the patient was 60 years old male who started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks 2 week plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehensive Nursing Assessment" dated 2/28/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. Patient 7 had mild dyspnea with mild exertion, and oxygen saturation was 97 percent. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, was check marked as "None". The need for the Volunteer or community support was blank. The nurse's narrative indicated Patient 7 was observed with on and off shortness of breath and was on Albuterol 90 mcg/Actuation inhalation Aerosol 90 mcg 1-2 puffs inhaler three times a day as needed for shortness of breath/wheezing. Patient 7 had generalized body pain and was on Norco 10 mg-325 mg one tablet by mouth every 6 hours as needed for pain. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 2/28/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 millimeter Mercury (mmHg). A review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 millimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 7's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient was 44 years old male who started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, Certification and as needed. The HA service and the volunteer services were offered and declined. A review of Patient 8's "Comprehensive Nursing Assessment" dated 1/21/2022 indicated Patient 8 was alert and oriented, needed stand by assist for ambulation. Patient 8 had mild dyspnea with mild exertion, and oxygen saturation was 92 percent. Patient 8 was continent in bowel and bladder. The need of Hospice aide, and the need of community support were check marked as "None". The need for the Volunteer was check marked for errands. The nurse's narrative indicated Patient 8 was 43 years old male with last hospitalization on 9/18/2021 to 9/21/2021 for evaluation and treatment of left lower extremity torn ligament. According to the patient, his condition had progressively deteriorated in the past few months, evidence of dyspnea with activity and even at rest. Upon assessment, the patient was sitting in a chair and had a pain level to be 8/10. The patient was placed with medication of Norco 10/325 mg one tablet orally every 6 hours as needed for moderate to severe pain and Tylenol 500 mg every 6 hours for breakthrough pain. At the end of the visit and assessment, the patient was noted relaxed without any discomfort, no shortness of breath, and the pain level was 0/10. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 1/21/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 1/21/2022 to 4/20/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the physician's narrative that Patient 8 no longer wants to continue aggressive treatment and stated he wanted comfort measures only. It was indicated in the section of "Certifying Physician Summary" that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 8's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8 were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians that Patient 5, 6, 7, 8, had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of the agency's comprehensive assessment revised in April 2017 indicated the agency must assure the data elements allow for measurement of outcomes, and the Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the medications the patients were currently taking, and the medication profiles were reviewed and updated for one of 13 sampled patients, (Patient 7). Patient 7's physician had ordered humalog (fast acting insulin for diabetes)insulin administration according to the sliding scale (a varied dose of insulin based on blood glucose level) result. The humalog insulin was not at the patient's house during the home visit and the physician's order was not carried out. This deficient practice had the potential to place the patient at risk of hyperglycemia (an excess of glucose in the bloodstream) or hypoglycemia (deficiency of glucose in the bloodstream). Findings: A review of Patient 7's clinical record indicated Patient 7's start of care (SOC) date was 5/24/2022, with diagnoses of cerebrovascular disease (a group of conditions that can lead to a cerebrovascular event, such as a stroke) , vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), and diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). A review of the Interdisciplinary Care Plan dated 5/24/2022 indicated the nurse was to instruct the caregiver of drug interactions/treatment indications, use and side effect. A review of the "Medication List/Signed Physician Order" indicated the physician had ordered on 5/23/2022 to administer lantus insulin (100 unit/ml) 5 unit subcutaneously (injection in the tissue) every night at bed time for controlling blood sugar, and to administer humalog insulin (100 unit/ml) per sliding scale before meals and at bed time as follows: 150 milligram (mg)/deciliter (dl) to 200 mg/dl = 0 unit 201 mg/dl to 250 mg/dl = 1 unit 251 mg/dl to 300 mg/dl = 2 unit 301 mg/dl to 350 mg/dl = 3 unit 351 mg/dl to 400 mg/dl = 4 unit more than 400 mg/dl = 5 units and call the physician A review of Patient 7's "Visit Frequency Grid" of Plan of Care File from 6/22/2022 to 8/17/2022 indicated the Skilled Nurse (SN) visits were 1-2 times a week, the hospice aide's visits were 1-2 times a week, the chaplain's visit was once a week, and the social worker's visit was not scheduled. On 8/24/2022, at 11 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 1 was observed lying in a low air mattress (type of mattress for wound management), awake. Family member 2 (FM 2) and Caregiver 1 were next to Patient 7. At 12:30 p.m., during a review of Patient 7's medication compared with the medication profile, it was noted humalog insulin was not at Patient 7's house. During an interview with FM 2, he stated he had not performed the sliding scale and administered the humalog insulin accordingly since the patient had received the hospice service, because nobody instructed him. During a concurrent interview with RN 1, he stated he had been reviewing the patient's medications. However, he was not able to answer why humalog insulin was not available at the Patient 7's house, and why nobody had explained to FM 2/caregiver regarding sliding scale and humalog insulin administration. RN 1 stated the nurse should have reviewed the medications and Medication List/Signed Physician Orders. A review of the agency's undated policy titled "Pharmacy Process and obtaining orders"indicated all visits begin with a review of the patient's plan of care which includes current medications.

Based on observation, interview and record review, the hospice agency failed to meet the Condition of Participation for interdisciplinary group (IDG), care planning, and coordination of services as follows: 1. The agency failed to include a physician's order of sliding scale ( a varied dose of insulin based on blood glucose level) and insulin (diabetic medicine) administration in the plan of care for 1 of 13 sampled patients, (Patient 7) Refer to L538. 2. The agency failed to ensure skilled nurse visits followed the frequency indicated in the "Plan of Care" (POC, carefully prepared outline of nursing care showing all of the patient's needs and the ways of meeting them; a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the patient; typically includes nursing diagnoses, nursing interventions, and outcomes) file for one of 13 sampled patients, (Patient 7). Refer to L 543. 3. The agency failed to ensure a patient's glucometer (a machine used to take blood sugar levels) was checked/calibrated (marking a measuring instrument with the necessary graduations; the resulting markings or settings), and failed to provide instruction regarding lantus insulin (medicine for high blood sugar levels) use for 1 of 13 sampled patients, (Patient 7). Refer to L 544. 4. The agency failed to notify the physician in a timely manner when a patient developed a new pressure wound (damage to an area of the skin caused by constant pressure on the area for a long time) and when the patient's pressure wound deteriorated (got worst) for one of 13 sampled patients, (Patient 7). Refer to L557. The cumulative effect of these systemic practices resulted in the Hospice agency's inability to ensure the provision of quality health care.

Based on observation, interview and record review, the hospice agency failed to administer humalog (fast acting insulin to treat diabetes-high blood sugar) insulin (100 unit/ml) per sliding scale (a varied dose of insulin based on blood glucose level) before meals and at bed time as ordered by the physician in the plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for one of 13 sampled patients, (Patient 7). This deficient practice had the potential to place the patient at risk for hyperglycemia (an excess of glucose in the bloodstream) or hypoglycemia (deficiency of glucose in the bloodstream). Findings: A review of Patient 7's clinical record indicated Patient 7's start of care (SOC) date was 5/24/2022, with diagnoses of cerebrovascular disease (a group of conditions that can lead to a cerebrovascular event, such as a stroke), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), and diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). A review of Patient 7's "RN - Initial Comprehensive Assessment" dated 5/25/2022 indicated Patient 7 was confused, and had a diabetic ulcer (open wounds or sores usually found on the bottom of feet) on the right foot. There was no documented evidence Patient 7's blood sugar was monitored. A review of Patient 7's "Visit Frequency Grid" of Plan of Care File from 6/22/2022 to 8/17/2022 indicated the Skilled Nurse (SN) visits were 1-2 times a week, the hospice aide's visits were 1-2 times a wee, the chaplain's visit was once a week, and the social worker's visit was not scheduled. A review of the "Medication List/Signed Physician Order" indicated the physician had ordered on 5/23/2022 to administer lantus insulin (100 unit/ml) 5 unit subcutaneously (injection in the tissues) every night at bed time for controlling blood sugar, and to administer humalog insulin (100 unit/ml) per sliding scale before meals and at bed time for blood sugar level results as follows: 150 milligram (mg)/deciliter (dl) to 200 mg/dl = 0 unit 201 mg/dl to 250 mg/dl = 1 unit 251 mg/dl to 300 mg/dl = 2 unit 301 mg/dl to 350 mg/dl = 3 unit 351 mg/dl to 400 mg/dl = 4 unit more than 400 mg/dl = 5 units and call the physician On 8/24/2022, at 11 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 1 was observed lying in a low air mattress (type of mattress for wound management), awake. Family member 2 (FM 2) and Caregiver 1 were next to Patient 7. At 12:30 p.m., during a review of Patient 7's medication reconciling with the medication profile, it was noted humalog insulin was not available at Patient 7's house. During an interview with FM 2, he stated he had not performed the sliding scale and administered the humalog insulin accordingly since the patient had received the hospice service, because nobody instructed him. During a concurrent interview with RN 1, he stated he had been reviewing the patient's medications. However, he was not able to answer why humalog insulin was not at the patient's home available, and why nobody had explained to FM 2/caregiver regarding sliding scale and humalog insulin administration. RN 1 stated the nurse should have reviewed the medications and Medication List/Signed Physician Orders. A review of the Interdisciplinary Care Plan dated 5/24/2022 indicated the nurse was to instruct the medication (drug interaction/treatment indications, use and side effect) and hospice training about medication. During an interview with the Director of Patient Care Services (DPCS) on 8/26/2022, at 2:10 p.m., she was not able to provide the documented evidence patient 7's blood sugar was monitored or instructed the caregiver/family about it. The DPCS stated the care plan should have been developed for the DM management including monitoring blood sugar and medication/insulin administration and the goals. A review of the agency's undated policy titled "Care planning" indicated the plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related condition.

Based on interview, and record review, the hospice agency failed to provide services in accordance to the plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for one of 13 sampled patients, (Patient 7). Patient 7's POC indicated Skilled Nurse (SN) services twice a week. The SN visited the patient once a week and did not follow the POC. This deficient practice had a potential to result in the patient's nursing and clinical needs will not be meet that could impact the patient's health status and well being. Findings: A review of Patient 7's clinical record indicated Patient 7's start of care (SOC) date was 5/24/2022, with terminal diagnosis of cerebrovascular disease (disease that affects the heart or blood vessels) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A review of Patient 7's "RN - Initial Comprehensive Assessment" dated 5/25/2022 indicated Patient 7 was confused and had a diabetic ulcer (open wounds or sores usually found on the bottom of feet) on the right foot. There was no assessment of diabetic ulcer with size, color, stage, or description of the diabetic ulcer. A review of Patient 7's "Visit Frequency Grid" of Plan of Care File from 6/22/2022 to 8/17/2022 indicated the Skilled Nurse (SN) visits was conducted once a week instead of twice a week: The week of 7/27/2022 to 8/2/2022 (SN visit-one time) and 8/10/2022 to 8/16/2022 (No SN visit). The hospice aide's visits were 1-2 times a week, the chaplain's visit was once a week, and the social worker's visit was not scheduled. A review of Patient 7's record indicated there was one SN visit for the week from 6/29/2022 to 7/5/2022, 7/6/2022 to 7/12/2022, and there was no SN visit from 7/27/2022 to 8/2/2022. On 8/25/2022, at 3 p.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence the SN had visited Patient 7 two times a week 6/29/2022 to 7/5/2022, 7/6/2022 to 7/12/2022, and the SN had visited the patient from 7/27/2022 to 8/2/2022. The DPCS was not able to locate the documented evidence the patient had declined the SN visit, and another make up visit had been scheduled. The DPCS stated the SN should have visited the patient as indicated in the POC. A review of the agency's undated policy titled "Team Visit Schedules" indicated if a visit is inadvertently missed, documentation should support measures taken to meet patient need and to reschedule with the patient/family and ensure their agreement with the change.

Based on observation, interview and record review, the hospice agency failed to ensure a patient's glucometer (a machine used to take blood sugar levels) was checked/calibrated (marking a measuring instrument with the necessary gradations; the resulting markings or settings), and failed to provide instruction to the caregiver regarding opened lantus (medicine for high blood sugar levels) insulin expires after 28 days it was opened for one of 13 sampled patients (Patient 7). This deficient practice had the potential for an incorrect blood sugar level results and the potential for the patient to take the expired insulin that could result to adverse effects and not meeting the therapeutic level (effectiveness) of medication. Findings: a. A review of Patient 7's clinical record indicated Patient 7's start of care (SOC) date was 5/24/2022, with diagnoses of cerebrovascular disease (a group of conditions that can lead to a cerebrovascular event, such as a stroke), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), and diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). A review of Patient 7's "RN - Initial Comprehensive Assessment" dated 5/25/2022 indicated Patient 7 was confused, and had a diabetic ulcer (an ulcer usually found on the feet) on the right foot. There was no documented evidence Patient 7's blood sugar was monitored. A review of Patient 7's "Visit Frequency Grid" of Plan of Care File from 6/22/2022 to 8/17/2022 indicated the Skilled Nurse (SN) visits were 1-2 times a week, the hospice aide's visits were 1-2 times a week, the chaplain's visit was once a week, and the social worker's visit was not scheduled. A review of the "Medication List/Signed Physician Order" indicated the physician had ordered on 5/23/2022 to administer lantus insulin (100 unit/ml) 5 units subcutaneously (injection in the tissues) every night at bed time for controlling blood sugar. On 8/24/2022, at 11 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 1 was observed lying in a low air mattress (a type of mattress for wound management), awake. Family member 2 (FM 2) and Caregiver 1 were next to Patient 7. At 12:30 p.m., during a review of Patient 7's medication, one lantus insulin pen was observed opened without an opened date labeled. FM 2 was asked about the date the lantus insulin pen was opened, stated he did not remember when it was opened, "may be approximately 1 1/2 months ago". FM 2 was again asked how long lantus insulin was good after it was opened, stated he did not know because nobody from the hospice staff told him. RN 1 was also asked how long lantus insulin was good after it was opened, RN 1 stated he was not sure how long it was good. On 8/26/2022, at 2:40 p.m., during an interview with the Director of Patient Care Services (DPCS), stated lantus insulin is good for 28 days after it is opened, and the nurse should have instructed the caregiver/family to label lantus insulin pen when it was opened. According to the agency's pharmacy guide, lantus insulin should be used in 28 days after it was opened. b. On 8/24/2022, at 12:30 p.m., during a home visit with Registered Nurse 1 (RN 1), Glucometer (a medical device for determining concentration of glucose/sugar in the blood) 1 was observed used by Patient 7. During an interview with FM 2 he stated he had been using Glucometer 1 for approximately 5 months. When asked FM 2 whether Glucometer 1 was tested/calibrated (the act or process of marking a measuring instrument with the necessary graduations; the resulting markings or settings) with control test solution, he stated he did not. FM 2 stated he was not aware Glucometer 1 was to be tested/calibrated because nobody told him. During an interview with RN 1, he was not sure Glucometer 1 was to be tested/calibrated. A review of Owner's booklet for Glucometer 1 indicated a control solution test should be performed to confirm that the meter and test strips are working properly. It indicated the control solution test results should fall within the range printed on the test strip vial label. If the control solution test results continue to fall outside the range printed on the test strip vial, do not use glucometer to test blood glucose.

Based on observation, interview and record review, the hospice agency (HA) failed to notify the physician promptly of patient's new developed pressure wound (damage to an area of the skin caused by constant pressure on the area for a long time) and the significant changes of the pressure wound for one of 13 sampled patients, (Patient 7). This deficient has the potential to result in the delay of treatment, intervention, and delay of the wound healing process that could lead to infection and complications. Findings: A review of Patient 7's clinical record indicated Patient 7's start of care (SOC) date was 5/24/2022, with terminal diagnosis of cerebrovascular disease (a group of conditions that can lead to a cerebrovascular event, such as a stroke) and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A review of the "Admission Orders/Hospice certification dated 5/24/2022 indicated the initial weekly staff visit frequency was once a week for the nurse, social worker, chaplain and the hospice aide. A review of "RN - Initial Comprehensive Assessment" dated 5/25/2022 indicated Patient 7 was confused and had a diabetic ulcer (an ulcer usually found on the feet) on the right foot. There was no assessment of diabetic ulcer with size, color, or description of the diabetic ulcer. It indicated "Wound Care not provided during the visit". A review of the "Nursing-Updated Comprehensive Assessment" dated 6/8/2022 indicated Patient 7 had pressure ulcers as follows: 1. Heel (did not indicate whether it was right or left) - Stage II, sized 5 cm (centimeters) by 2 cm 2. Left buttock - Stage II, sized 3 cm by 4 cm 3. Right buttock - Stage II, sized 2 cm by 2 cm However, there was no documented evidence the physician was notified regarding above pressure ulcers. There was a physician's order dated 6/10/2022 to cleanse right and left buttocks bed sores with normal saline (cleansing solution), pat dry and to apply island dressings/maple (type of dressing) every 3 days or as needed. A review of the physician's order dated 6/20/2022 indicated to provide the low air mattress (type of mattress for wound management) as soon as possible. A review of the "Nursing-Updated Comprehensive Assessment" dated 7/7/2022 indicated Patient 7 had one Stage III (are deep and painful wounds in the skin) pressure ulcer on the sacrum sized 3 cm by 3 cm by 0.5 cm , and two Stage II (skin that breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure ulcers on the right cuff and left heel. A review of Patient 7's record indicated there was no documented evidence the physician was notified regarding aggravated pressure ulcer on the sacrum [from Stage II to Stage III (are deep and painful wounds in the skin) ]. There was no new physician's order in the record since 6/20/2022. A review of the "Nursing-Updated Comprehensive Assessment" dated 7/13/2022 indicated Patient 7 had one Stage IV (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) pressure ulcer on the sacrum. There was no size measurement, or description of the Stage IV pressure ulcer on the sacrum. A review of Patient 7's record indicated there was no documented evidence the physician was notified regarding aggravated pressure ulcer on the sacrum (from Stage III to Stage IV). Also, there was no new physician's order in the record since 6/20/2022 On 8/24/2022, at 11 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 1 was observed lying in a low air mattress. Family member 2 and Caregiver 1 were next to Patient 7. At 11:30 a.m., during treatment observation by RN 1, patient 7 was observed having Stage IV pressure ulcer on the sacral area sized 8 cm by 7 cm by 3 cm [with 3 cm of tunneling (a wound that's progressed to form passageways underneath the surface of the skin) ], unstageable ulcers (covered with black scab) on the right heel (sized 1 cm by 4 cm) and left heel (7 cm by 6 cm). Part of the pressure ulcer on the sacrum was yellowish white color. During an interview with RN 1, he stated it could be pus, which meant it was infected. RN 1 stated he would call the physician for a new order. During an interview with the Director of patient Care Services (DPCS) on 8/25/2022, at 3 p.m., she stated she was not able to find the documented evidence the physician was notified regarding the deterioration of pressure ulcer on the sacral area, and no documented evidence the Interdisciplinary group (IDG) team had discussed about the wound. A review of the agency's undated policy titled "Pharmacy Process and Obtaining Orders" indicated to ensure new symptoms are managed in a timely manner and to report new symptoms to the physician and order new medications as directed from the pharmacy for a timely delivery.

Based on interview and record review, the Hospice Agency failed to ensure that a supervisory visit for hospice aide was conducted every 14 days for three of seven sampled patients (Patients 2, 3, and 4). This deficient practice resulted in lack of oversight and had the potential to result in services not being provided. Findings: a. A review of Patient 2's clinical record indicated the patient was admitted on 3/04/2022, with diagnoses which included Alzheimer's disease (it is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), and dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 2's "Admission Orders/Hospice Certification", dated 3/04/2022, indicated Patient 2 has a terminal diagnosis for which palliative care was considered appropriate and that the patient has a life expectancy of 6 months or less if the illness runs its normal course. It also indicated the skilled nurse (SN) and the hospice aide (HA) to visit the patient once a week. A review of Patient 2's clinical record indicated there were no HA supervisory visits conducted on the dates between 7/04/2022 to 7/31/2022, and between 7/31/2022 to 8/19/2022. b. A review of Patient 3's clinical record indicated the patient was admitted on 1/21/2021, with diagnoses which included cerebrovascular disease (or called a stroke, it happens when there is a loss of blood flow to part of the brain), and vascular dementia (brain damage caused by multiple strokes) without behavioral disturbance. A review of Patient 3's Plan of Care (POC) File: Visit Frequency Grid, for the recertification period starting from 5/17/2022 to 7/16/2022, and from 7/16/2022 to 9/14/2022, indicated for the skilled nurse (SN) to visit once a week and for the HA to visit twice a week. A review of Patient 3's clinical record indicated there were no HA supervisory visits conducted from 6/17/2022 to 7/27/2022, and from 7/31/2022 to 8/19/2022. c. A review of Patient 4's clinical record indicated the patient was admitted on 3/27/2022, with diagnoses which included malignant neoplasm (a cancerous tumor) of stomach, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Patient 4's Plan of Care (POC) File: Visit Frequency Grid, for the recertification period starting from 5/26/2022 to 7/25/2022, and from 7/25/2022 to 9/23/2022, indicated for the HA to visit once a week. A review of Patient 3's clinical record indicated there were no HA supervisory visits conducted from 6/22/2022 to 8/19/2022. On 8/26/2022, at 1:10 p.m., an interview and concurrent clinical record review was conducted with the Director of Patient Care Services (DPCS). DPCS was informed and acknowledged the findings. The DPCS stated HA supervisory visit should be conducted every 14 days by the registered nurse (RN). A review of the agency's policy and procedure titled "Vitas Standard (VS) Supervision Delegation and Coordination", updated 7/15/2019, indicated the RN should provide direction and guidance to the HA and LVN (licensed vocational nurse) based on his or her evaluation of the performance of the delegated tasks. The RN must complete a HA supervisory visit during the nursing visit to the patient at least every 14 days when hospice aide services are on the plan of care.

Based on observation, interview and record review, the hospice agency failed to ensure volunteer service was offered /provided to the patients for 2 of 13 sample patients (Patients 7, and 8). This deficient practice has the potential for the patient's needs to receive volunteer services will not be met as required. Findings: a. A review of Patient 7's clinical record indicated Patient 7's start of care (SOC) date was 5/24/2022, with terminal diagnosis of cerebrovascular disease and vascular dementia. A review of Patient 7's "Visit Frequency Grid" of Plan of Care File from 6/22/2022 to 8/17/2022 indicated the Skilled Nurse (SN) visits were 2 times a week except the week from 7/27/2022 to 8/2/2022 (SN visit-one time) and 8/10/2022 to 8/16/2022 (No SN visit). the hospice aide's visits were 1-2 times a week, the chaplain's visit was once a week, and the social worker's visit was not scheduled. There was no indication regarding the volunteer service. On 8/24/2022, at 11 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 1 was observed lying in a low air mattress. Family member 2 (FM 2) and Caregiver 1 were next to Patient 7. During an interview with FM 2 at 11:55 a.m., he stated nobody had explained and offered the volunteer service since admission, and he had not refused the volunteer service. When RN 1 explained about the volunteer service, FM 2 stated he would like to receive the volunteer service. b. A review of Patient 8's clinical record indicated Patient 7's start of care (SOC) date was 5/24/2022, with terminal diagnosis of cerebrovascular disease and vascular dementia. A review of Patient 8's "Visit Frequency Grid" of Plan of Care File from 6/29/2022 to 8/17/2022 indicated the Skilled Nurse (SN) visits were 1-2 times a week, the hospice aide's visits were 0-2 times a week, the social worker and the chaplain's visit was once a month. There was no indication regarding the volunteer service. On 8/24/2022, at 1:10 p.m., during a home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 8 was observed lying in bed. Family Member 3 (FM 3) and Caregiver 2 were next to Patient 7. During an interview with FM 3 at 1:30 p.m., he stated nobody had explained and offered the volunteer service since admission, and he had not refused the volunteer service. When LVN 1 explained about the volunteer service, FM 3 stated he would love to receive the volunteer service, and he wished he knew about the volunteer service earlier because he really needed that kind of services. During an interview with the volunteer manager on 8/25/2022, at 1:40 p.m., she stated when a patient is admit to the agency, any team member (Registered Nurse, social worker, chaplain) would assess the need of volunteer service and make recommendations to her. The volunteer manager stated the agency provide the volunteer service based on the other discipline's recommendation and she had not assessed the volunteer service need. A review of the agency's undated policy titled "Volunteer Visit" indicated the hospice must use volunteers, and these volunteers must be used in defined roles and under the supervision of a designated hospice employee. Team and patient/family identification of need for volunteer need include: 1. Relief care for caregiver 2. socialization, emotional support 3. transportation, outings 4. Light household chores 5. Shopping 6. Bereavement support 7. Telephone assurance 8. Specialty services 9. Reading, games, playing music A review of Patient 7's and Patient 8's record indicated there was no documented evidence above volunteer service/role was explained to the caregiver/family.

Based on observation, interview, and record review, the hospice agency failed to review all the medications and update the medication profile for one of 13 sampled patients (Patient 1). This failure placed the patient at a potential risk for medication errors and adverse (harmful) drug reactions. Findings: A review of Patient 1's clinical record indicated the patient was admitted on 8/31/2020, with diagnoses that includes Alzheimer's disease ((it is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), and dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 1's Plan of Care (POC) File: Visit Frequency Grid, for the recertification period starting from 6/22/2022 to 8/21/2022, indicated for the skilled nurse (SN) to visit once every 2 weeks and for the hospice aide (HA) to visit twice a week. A review of Patient 1's Interdisciplinary Plan of Care Revision (IPOC)/Physician Orders, dated 6/08/2022, indicated an order for the SN to review medications and recommend or change for/with by the patient's caregiver if indicated. The IPOC, dated 8/03/2022, indicated an order for the SN to educate family on safety of medication administration. During a joint home visit at Patient 1's residence with the registered nurse (RN 2), on 8/24/2022 at 10:25 a.m., Patient 1 was observed lying in a hospital bed, and a family member (FM 1), the primary caregiver was next to the patient and available to answer any questions. During a review of Patient 1's current medications on 8/24/2022 at 10:45 a.m., Ativan (medication used to treat anxiety) 1 milligram (mg, a unit of measure) 1 tablet by mouth daily was not found. However, the hospice's current medication list indicated the patient was taking the medication. During an interview with FM 1, on 8/24/2022 at 10:50 a.m., FM 1 stated, "I stopped using Ativan 8-9 months ago because my brother has gotten worse after taking it". During an interview with the Director of Patient Care Services (DPCS), on 8/26/2022 at 1:10 p.m., the DPCS stated staff needed to review the medication the patient was currently taking on every nurse visit. The DON stated the nursing staff need to check to see if there are changes such as new orders, or discontinued orders that way they can update the medication list or call the physician for orders. A review of the agency's policy and procedure titled "Vitas Standard (VS) Pharmacy Process and Obtaining Orders", dated 9/24/2021, indicated the Chart Medication List (CML)/Signed Physician Orders is the part of the plan of care that lists the pharmacological interventions for each patient. The purpose of the CML is to communicate all authenticated medications (active or discontinued), document the reason of symptom for which the medication is used, document coverage of medication, and communicate/facilitate physician oversight/review the patient's medication. The CML should be reviewed during each patient visit to ensure it is up to date including active and discontinued medications.